484
Journal of the Royal Society of Medicine Volume 84 August 1991
The changing pattern of thoracic surgery United Kingdom 1963-1982
in
the
J A Paraskevopoulos MD FRCS1 A J Gunning FRCS2 A R Dennison MD FRCS' Hallamshire Hospital, Sheffield and 2Groote Schuur Hospital4 Cape Town, South Africa
'Royal
Keywords: cardiothoracic surgery; changing practice
Summary During the period 1963-1982 a total of 11 459 patients with general surgical and thoracic conditions were admitted to the Churchill and John Radcliffe Hospitals in Oxford under the care of a single thoracic surgeon. 55.1% of the admissions were for general surgical conditions whereas 44.9% were for a thoracic disorder. The total period has been studied by dividing it into three subgroups of 7, 6 and 7 years (1963-1969, 1970-1975, 1976-1982). The percentage of thoracic patients treated during the three periods was found to be 48.86%, 41.73% and 50.11% respectively. The three periods studied have been subdivided int major disease groups and the changes in these groups have been studied in detail. During this 20-year period there has been a dramatic change in the makeup of a typical thoracic surgical practice. This is in part due to the changing- pattern and prevalence of many of the diseases treated by thoracic surgeons, but is also -due to a change in referral patterns, the distribution of patients between thoracic and general surgeons and also the dichotomy emerging between thoracic and cardiac surgeons. Introduction The development of cardiothoracic surgery as a separate specialty and an increasing tendency to separate it into two separate disciplines, cardiac and thoracic surgery, is the outcome of many events during the 20th century. Of these many factors, however, four seem to have been most influential'. First, the ability of thoracic surgeons to deal with an increasing variety of complex lung disorders, especially between the First and Second World Wars. Second, the continuing decrease in the incidence of acquired cardiothoracic diseases such;as mitral stenosis, and due to improved sanitary conditions and the revolutionary contribution of the antibiotics in the treatment of chest infections, the reduction of pulmonary tuberculosis and empyema. Third,- the alteration of referral patterns due to the development of regional specialized bentres equipped with modern laboratory facilities, intensive care units and properly trained medical and nursing staff. Finally, the demonstration of dramatic improvement in results of surgery in conditions previously thought to be better dealt with conservatively. This was the logical consequence ofbetter and adequate surgical training and of major improvements in anaesthesia, anti-
biotics, hypothermia, cardiopulmonary bypass and blood transfusion. There remained, however, a considerable difference in the practice of cardiothoracic surgery in the USA and UK- as the majority -of surgeons, in the UK continued to devote a large part of-their time to general surgery (unlike the USA where specialization in cardiac surgery started much -earlier). Indeed, in the UK -appointments with an exclusive cardiac surgical interest did not begin to appear. until the 1960s2. This study was conducted in order to assess the impact ofthese factors op 'thoracic' surgery in the UK, over the 20 year period (1963-1982) when the effects were likely to be most marked.
Patients and methods The period surveyed was from January 1963 to December 1982. The area served by the Churchill and John Radcliffe Hospitals was studied and all general and thoracic surgical cases admitted under Mr A Gunning during that period were identified using the hospitals' diagnostic indices, theatre records and discharge summaries. Results Between 1963 and 1982, 11 459 patients (6971 men, 4488 women, M: F=1.55) with general surgical and thoracic diseases were admitted to the two hospitals. There were 6313 patients (3632 men, 2681 women, M: F=1.35) with general surgical problems and a total of 5146 (3344 men, 1807 women, M: F 1.85) with thoracic -surgical problems. General surgical cases constituted 55.1 % of the total, and thoracic surgical cases 44.9% (Figure 1). 1200
00S
goS 'OS
600 400
200
0141-0768/91/ 1 34 '5 '6 7 Is'
Correspondence to J A Paraskevopoulos, University Department of Surgery, Floor K, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF
.-
o
F '3 :
-.
*
080484-04A02.00/0 .
%
*
Figure 1. Distribution of general surgical and thoracic patients during the period 1963-1982
@191
.rThe .t Royaed ;-; Society of Medicine
@
Journal of the Royal Society of Medicine Volume 84 August 1991 Table 1. Method of classification of surgical diseases
General surgery 1 Breast 2 Abdomen (including herniae) 3 Genito-urinary 4 Oesophagus: tumours other conditions 5 Miscellaneous
Thoracic surgery 1 Lung tumours: benign
malignant 2 Chest tumours: ribs, sternum
heart mediastinum thymus
Tuberculosis Bronchiectasis Lung abscess Empyema Pneumothorax Trauma: open closed 9 Foreign bodies 10 Miscellaneous 3 4 5 6 7 8
Dividing the above studied 20-year period into three subgroups (I: 1963-1969, II: 1970-1975 and III: 1976-1982) allows the change with time to be studied in greater detail in the separate conditions defined in Table 1. During period I, 2464 patients (21.50% of the total: 352.0 per year) were admitted; 1260 (51.14%) general surgical problems and 1201 (48.86%) thoracic problems. During period II, almost twice as many patients, 5480 (46% of the total: 913.0 per year) were admitted; 3193 (58.27%) with general surgical disorders and 2077 (41.75%) with thoracic problems. Finally, during period III, the number was reduced and 3728 patients (32.5% of the total: 532.6 per year) were admitted of whom 1860 (49.89%) had general surgical problems and 1868 (50.11%) thoracic disorders. To allow us to study the changing pattern of specific conditions we classified all patients into one of 15 major groups as shown in Table 1. Discussion Thoracic surgery continues to mean different things to different people, particularly in the UK, where the official British interpretation, that it is the surgery ofthe body from the hyoid bone above to the umbilicus below, remains3. Major surgery in this area and subsequently the development of cardiac surgery as a separate specialty was the result of major advances in the knowledge of the pathophysiological processes affecting thoracic organs. These developments were particularly marked from the first part of the 20th century to the Second World War with the steady progress of pulmonary and oesophageal surgery together with the emergence of closed cardiovascular surgery. Expansion during the Second World War was the result of innovative developments in all areas, but particularly due to improved knowledge ofbasic pathology and physiology and the availability of cardiopulmonary bypass, synthetic vascular grafts and valvular prostheses. Coronary bypass procedures, hypothermia, antibiotics, improved intensive care facilities, advances in anaesthesia and blood transfusion allowed further rapid advances and inevitably meant that individual surgeons tended to choose between one or other specialty. In this respect, the USA preceded the UK where some surgeons even continued to combine thoracic and general surgical practice.
The increasing volume of cardiac surgery, however, tended to relegate thoracic surgery to a secondary position, obvious both in the USA and UK. As a result up to 1979, the commonest makeup of a cardiothoracic surgical practice in the UK was 100% thoracic surgery or 75% cardiac plus 25% thoracic surgery2. Furthermore, many thoracic procedures, especially involving oesophageal diseases, were increasingly being performed by general surgeons with a special interest in these areas. This 'competition' has resulted in a substantial change in the thoracic workload of general surgery and vice versa, and has also been partly responsible for the tendency ofphysicians and general surgeons to perform fibreoptic endoscopy (bronchoscopy, oesophagoscopy) under local anaesthesia whereas previously rigid endoscopy had belonged exclusively to the thoracic surgeon4. In the USA it is difficult to determine how many certified thoracic surgeons actually practice thoracic surgery exclusively. Up to the beginning of 1980s there were 2063 American thoracic surgeons, a ratio of approximately one thoracic surgeon per 100 000 population which was five times the corresponding ratio in UK5. Further evidence of the 'continuous competition' comes from the work of Adkins and Orthner which showed that almost 20% ofthe thoracic surgical procedures are performed by non-certified thoracic (eg general) surgeons in the USA6. In addition, nearly two-thirds of the American thoracic surgeons have a secondary specialty, general surgery being the most common (approximately 50%), with cardiac or vascular surgery comprising the majority of the rest7. Corresponding percentages are not available for the UK but from our own figures it can be seen that although there are many similarities, there are some striking differences, particularly in the overall development of the specialty. In Figure 1 it can be seen that of the total patients studied only 44.9% (5146) were admitted for thoracic problems, this being approximately half the corresponding figure for surgeons in the USA6. This may reflect the lack offormal certification in the UK which allows a greater flexibility in admission patterns largely influenced by personal preference on behalf of the surgeon5. This is again in stark contrast to the USA where the overall Board certification rate of thoracic surgeons is the highest (90%o) of any surgical specialty7. Thus whilst clear differences obviously exist between the practice of thoracic surgeons in the UK and the USA in respect of working practice, the distribution ofthoracic disease has many similarities. During the first two periods ofthe study pulmonary tuberculosis and pulmonary and intrapleural sepsis constituted the majority of the workload of the thoracic surgeon (Figures 2-4). These figures also 10 8
F
v Male Female
'80
'82
Year
Figure 2. Distribution of tuberculosis between 1963 and 1982
485
486
Journal of the Royal Society of Medicine Volume 84 August 1991
10 r
24 r
E
Male
D
Female
20 -
8 '
:
16
,, 1 2
4 !t
8
I;
4
2
11964
'66
'68
'l0
Y172 Year
74
176
'T8
'80
L 182
Figure 3. Incidence of lung abscess between 1963 and 1982
demonstrate the impact of the introduction of antibiotics on the incidence of lung abscess and the natural history of empyema, which has been entirely altered. In combination with antibiotics, effective chemotherapy, BCG vaccination and environmental developments have also drastically reduced the incidence of pulmonary tuberculosis and consequently secondary infectious problems2. Lung cancer remains by far the most common fatal cancer in British men and currently causes approximately 35 000 deaths a year in England and Wales8. The overall mortality is still 80% within a year of diagnosis and nowadays surgical treatment of lung cancer has become almost the raison d'etre of the thoracic surgeon, reflected in the fact that 95% of lung resections are carried out for lung carcinoma9. The most striking feature ofthis fatal condition is the change in incidence of the disease between the sexes. In Figure 5 it can be seen that lung cancer was substantially more common in men during the late 1960s with a peak in women during the next decade. This difference in sex incidence is consistent with the effects of smoking which became popular among women later than among men8. Unfortunately, despite great improvements in the availability of specialized anaesthetists and radiographic and pathological diagnostic facilities, there have been no improvements in the survival rates following surgery and mortality figures have remained static over the last 30-40 years. This is supported by the findings of Bates (who studied 2430 patients treated from 1950 to 1978) and Belcher (8781 patients operated on for lung carcinoma between 1949 and 1980)10,11, whose figures show that the disease process itself is the dominant factor influencing the outcome of treatment. This lack of improvement for primary lung carcinoma contrasts with the long-term survival of patients who undergo lung surgery for metastatic malignant disease of the lung. In these cases provided that the EMPYEMA 24
go Male
20
F]Female
H
11/4
1963 4
5 6
7
8
9 1970 1
2 3
4
5
6
7
8
9 198
1
2 3
Figure 5. Distribution oflung carcinoma between 1963 and 1982
primary tumour has been completely removed and where there is no evidence of other metastatic spread, there is a 33% 5-year survival rate'2. There have been similar changes in the incidence of chest trauma and foreign bodies in our series, but the underlying reasons for this are probably quite different. Originally (up to the mid-1970s) the majority of -these patients were referred to general surgeons, but more recently an increasing number are being treated by thoracic surgeons. This has been facilitated by the recent establishment of properly organized regional cardiothoracic units, that ensures that the patient with major thoracic problems will be seen and treated immediately by an experienced thoracic surgeon8. Finally the distribution of general surgical conditions including non-malignant oesophageal conditions, oesophageal tumours, abdominal herniae, breast disease, genitourinary problems and other miscellaneous general surgical conditions, has also been influenced by these changes. They serve to further emphasize the (as is popularly thought) 'competition' between general and thoracic surgeons. This is nowhere keener than in the field of oesophageal surgery. General surgeons operated increasingly on oesophageal disease during the second half of the surveyed 20-year period and this was probably responsible for the majority of the falls in referrals to thoracic surgeons. This is due in part to the emergence of a number of general surgeons with ..a special interest in oesophageal diseases, but also to general improvements that have occurred in anaesthesia and supportive care allowing major surgery to be performed in an increasing variety of surgical units'3. The introduction of transhiatal oesophagectomy and the recently reported remarkable 5-year survival rates (after en-bloc resection of oesophageal tumours of 20-34.7%) have led to a further shift in the distribution of oesophageal
surgery'4"5 It is clear from our study that general surgeons are increasingly undertaking major procedures,
16 12 8 4
Year
Figure 4. Incidence of empyema between 1963 and 1982
previously the domain of the thoracic surgeons. This increase has taken place progressively over the last 20-30 years and probably -reflects a number of influences including the fact that many of the cardiothoracic surgeons (at least of the younger generation) have been attracted by the striking evolution of cardiac surgery, leaving more space for thoracic conditions to be dealt with by general surgeons with a special interest.
Journal of the Royal Society of Medicine Volume 84 August 1991 References 1 Paulson DL. A time for assessment. J Thorac Cardiovasc Surg 1981;82:163-8 2 English TAH. Future of cardiothoracic surgery. Thorax 1979;34:443-6 3 Allison PR, Temple LJ. The future of thoracic surgery. Thorax 1966;21:99-103 4 Mitchell DM, Emerson CJ, Collyer J, Collins JV. Fibreoptic bronchoscopy: ten years on. BMJ 1980;281:360-3 5 Ellis FH Jr. Education of the thoracic surgeon. Thorax 1980;35:405-14 6 Adkins PC, Orthner HF. The society ofthoracic surgeons manpower survey for 1976: a summary. Ann Thorac Surg 1979;28:407-12 7 Bloom BS, Nickerson RJ, Hauck WW Jr, Peterson OL. Thoracic surgeons and their surgical practice. J Thorac Cardiovasc Surg 1979;78:167-74 8 Coggon D, Acheson ED. Trends in lung cancer mortality. Thorax 1983;38:721-3
Forthcoming events
3rd Annual Meeting of the British Sleep Society 1-3 September 1991, Worcester College, Oxford Further details from: Dr J Stradling, Osler Chest Unit, Churchill Hospital, Headington, Oxford OX3 7LJ (Tel: 0865 225236; Fax: 0865 225221) Good Clinical Practice: A Basic Course 5-6 September 1991, National Heart & Lung Institute, London Further details from. Christine Bull, Rostrum, Lewis House, 1 Mildmay Road, Romford RM7 7DA (Tel: 0708 745042; Fax: 0708 725413) 7th IUVDT Regional Conference on Sexually Transmitted Diseases 5-7 September 1991, Kuala Lumpur, Malaysia Further details from: Conference Secretariat, Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 59100 Kuala Lumpur, Malaysia (Tel: 03 7502264; Fax: 603 7557740) Introduction to Regulatory Affairs 9-10 September 1991, Royal Society of Medicine, London Further details from: (see entry for 5-6 September 1991)
Uveitis & Retina Frontiers: Diagnostic, Medical and Surgical Approaches 13-15 September 1991, Carmel Valley Ranch Resort, California Further details from: University of California, Extended Programs in Medical Education, Room LS-105, San Franciso, CA 94143-0742, USA (Tel: 415 476-4251; Fax: 415 476-0318)
Schizophrenia: Neurobiology, Clinical Aspects and Trial Designs 16-17 September 1991, Royal Society of Medicine, London Further details from: (see entry for 5-6 September 1991) Detection & Management of Fraud in Clinical Research 19-20 September 1991, National Heart & Lung Institute, London Further details from: (see entry for 5-6 September 1991)
9 Smith RA. Development of lung surgery in the United Kingdom. Thorax 1982;37:161-8 10 Bates M. Surgical treatment of bronchial carcinoma. Ann R Coll Surg Engl 1981;63:164-7 11 Belcher JR. Thirty years of surgery for carcinoma ofthe bronchus. Thorax 1983;38:428-32 12 Marks P, Ferrag MZ, Ashraf H. Rationale for the surgical treatment of pulmonary metastases. Thorax 1981;36:679-82 13 Collis JL. The history of British oesophageal surgery. Thorax 1982;37: 795-802 14 Wong J. Transhiatal oesophagectomy for carcinoma of the thoracic oesophagus. Br J Surg 1986;73: 89-90 15 Hennessy TPJ. Choice of treatment in carcinoma of the oesophagus. Br J Surg 1988;75:193-4
(Accepted 20 November 1990)
Look After Your Heart International Conference: Collaboration, Co-operation and Community Participation 19-20 September 1991, London Further details from: Judy Berry, Health Education Authority, Hamilton House, Mabledon Place, London WC1H 9TX (Tel: 071-383 3833; Fax: 071-387 0550) Current Issues in Infection & Antimicrobial Therapy 24-25 September 1991, National Heart & Lung Institute, London Further details from: (see entry for 5-6 September 1991) Colposcopy 24-25 September 1991, Royal College of Obstetricians & Gynaecologists, London Further details from: Postgraduate Education Department, The Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent's Park, London NW1 4RG (Tel: 071-262 5425, ext 207) Monitoring of Orthopaedic Implant Biomaterials: Microelectronics Challenge 25-28 September 1991, Brussels Further details from: F Burny, Service OrthopedieTraumatologie, Universith Libre de Bruxelles, Route de Lennik 808, B 1070 Bruxelles, Belgium (Tel: 2-526 36 45; Fax: 2-520 35 56) Transitional and Community Care of Patients with Neurological Disabilities 27 September 1991, Oswestry, Shropshire Further details from: Erica Wilkinson, Institute of Orthopaedics, The Robert Jones & Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire (Tel: 0691 655311 ext. 3392) Initial Total Care of the Patient with Spinal Injuries 28 September 1991, Oswestry, Shropshire Further details from: (see previous entry) Autumn Meeting of the British Association of Oral and Maxillofacial Surgeons 27-29 September 1991, Harrogate Conference Centre Further details from: John C Lowry, Honorary Secretary, British Assciation of Oral and Maxillofacial Surgeons, Royal College of Surgeons of England, 35/43 Lincoln's Inn Fields, London WC2A 3PN MEDART International: First World Congress on Arts Medicine 29 September to 4 October 1991, The Hague, The Netherlands Further details from: Hoboken Congress Organization, Erasmus University, POB 1738, 3000 DR Rotterdam, The Netherlands (Tel: 31(0)10408 7881; Fax 31(0)10-436 7271) continued on p492
487
Journal of the Royal Society of Medicine Volume 84 August 1991
The changing pattern of thoracic surgery United Kingdom 1963-1982
in
the
J A Paraskevopoulos MD FRCS1 A J Gunning FRCS2 A R Dennison MD FRCS' Hallamshire Hospital, Sheffield and 2Groote Schuur Hospital4 Cape Town, South Africa
'Royal
Keywords: cardiothoracic surgery; changing practice
Summary During the period 1963-1982 a total of 11 459 patients with general surgical and thoracic conditions were admitted to the Churchill and John Radcliffe Hospitals in Oxford under the care of a single thoracic surgeon. 55.1% of the admissions were for general surgical conditions whereas 44.9% were for a thoracic disorder. The total period has been studied by dividing it into three subgroups of 7, 6 and 7 years (1963-1969, 1970-1975, 1976-1982). The percentage of thoracic patients treated during the three periods was found to be 48.86%, 41.73% and 50.11% respectively. The three periods studied have been subdivided int major disease groups and the changes in these groups have been studied in detail. During this 20-year period there has been a dramatic change in the makeup of a typical thoracic surgical practice. This is in part due to the changing- pattern and prevalence of many of the diseases treated by thoracic surgeons, but is also -due to a change in referral patterns, the distribution of patients between thoracic and general surgeons and also the dichotomy emerging between thoracic and cardiac surgeons. Introduction The development of cardiothoracic surgery as a separate specialty and an increasing tendency to separate it into two separate disciplines, cardiac and thoracic surgery, is the outcome of many events during the 20th century. Of these many factors, however, four seem to have been most influential'. First, the ability of thoracic surgeons to deal with an increasing variety of complex lung disorders, especially between the First and Second World Wars. Second, the continuing decrease in the incidence of acquired cardiothoracic diseases such;as mitral stenosis, and due to improved sanitary conditions and the revolutionary contribution of the antibiotics in the treatment of chest infections, the reduction of pulmonary tuberculosis and empyema. Third,- the alteration of referral patterns due to the development of regional specialized bentres equipped with modern laboratory facilities, intensive care units and properly trained medical and nursing staff. Finally, the demonstration of dramatic improvement in results of surgery in conditions previously thought to be better dealt with conservatively. This was the logical consequence ofbetter and adequate surgical training and of major improvements in anaesthesia, anti-
biotics, hypothermia, cardiopulmonary bypass and blood transfusion. There remained, however, a considerable difference in the practice of cardiothoracic surgery in the USA and UK- as the majority -of surgeons, in the UK continued to devote a large part of-their time to general surgery (unlike the USA where specialization in cardiac surgery started much -earlier). Indeed, in the UK -appointments with an exclusive cardiac surgical interest did not begin to appear. until the 1960s2. This study was conducted in order to assess the impact ofthese factors op 'thoracic' surgery in the UK, over the 20 year period (1963-1982) when the effects were likely to be most marked.
Patients and methods The period surveyed was from January 1963 to December 1982. The area served by the Churchill and John Radcliffe Hospitals was studied and all general and thoracic surgical cases admitted under Mr A Gunning during that period were identified using the hospitals' diagnostic indices, theatre records and discharge summaries. Results Between 1963 and 1982, 11 459 patients (6971 men, 4488 women, M: F=1.55) with general surgical and thoracic diseases were admitted to the two hospitals. There were 6313 patients (3632 men, 2681 women, M: F=1.35) with general surgical problems and a total of 5146 (3344 men, 1807 women, M: F 1.85) with thoracic -surgical problems. General surgical cases constituted 55.1 % of the total, and thoracic surgical cases 44.9% (Figure 1). 1200
00S
goS 'OS
600 400
200
0141-0768/91/ 1 34 '5 '6 7 Is'
Correspondence to J A Paraskevopoulos, University Department of Surgery, Floor K, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF
.-
o
F '3 :
-.
*
080484-04A02.00/0 .
%
*
Figure 1. Distribution of general surgical and thoracic patients during the period 1963-1982
@191
.rThe .t Royaed ;-; Society of Medicine
@
Journal of the Royal Society of Medicine Volume 84 August 1991 Table 1. Method of classification of surgical diseases
General surgery 1 Breast 2 Abdomen (including herniae) 3 Genito-urinary 4 Oesophagus: tumours other conditions 5 Miscellaneous
Thoracic surgery 1 Lung tumours: benign
malignant 2 Chest tumours: ribs, sternum
heart mediastinum thymus
Tuberculosis Bronchiectasis Lung abscess Empyema Pneumothorax Trauma: open closed 9 Foreign bodies 10 Miscellaneous 3 4 5 6 7 8
Dividing the above studied 20-year period into three subgroups (I: 1963-1969, II: 1970-1975 and III: 1976-1982) allows the change with time to be studied in greater detail in the separate conditions defined in Table 1. During period I, 2464 patients (21.50% of the total: 352.0 per year) were admitted; 1260 (51.14%) general surgical problems and 1201 (48.86%) thoracic problems. During period II, almost twice as many patients, 5480 (46% of the total: 913.0 per year) were admitted; 3193 (58.27%) with general surgical disorders and 2077 (41.75%) with thoracic problems. Finally, during period III, the number was reduced and 3728 patients (32.5% of the total: 532.6 per year) were admitted of whom 1860 (49.89%) had general surgical problems and 1868 (50.11%) thoracic disorders. To allow us to study the changing pattern of specific conditions we classified all patients into one of 15 major groups as shown in Table 1. Discussion Thoracic surgery continues to mean different things to different people, particularly in the UK, where the official British interpretation, that it is the surgery ofthe body from the hyoid bone above to the umbilicus below, remains3. Major surgery in this area and subsequently the development of cardiac surgery as a separate specialty was the result of major advances in the knowledge of the pathophysiological processes affecting thoracic organs. These developments were particularly marked from the first part of the 20th century to the Second World War with the steady progress of pulmonary and oesophageal surgery together with the emergence of closed cardiovascular surgery. Expansion during the Second World War was the result of innovative developments in all areas, but particularly due to improved knowledge ofbasic pathology and physiology and the availability of cardiopulmonary bypass, synthetic vascular grafts and valvular prostheses. Coronary bypass procedures, hypothermia, antibiotics, improved intensive care facilities, advances in anaesthesia and blood transfusion allowed further rapid advances and inevitably meant that individual surgeons tended to choose between one or other specialty. In this respect, the USA preceded the UK where some surgeons even continued to combine thoracic and general surgical practice.
The increasing volume of cardiac surgery, however, tended to relegate thoracic surgery to a secondary position, obvious both in the USA and UK. As a result up to 1979, the commonest makeup of a cardiothoracic surgical practice in the UK was 100% thoracic surgery or 75% cardiac plus 25% thoracic surgery2. Furthermore, many thoracic procedures, especially involving oesophageal diseases, were increasingly being performed by general surgeons with a special interest in these areas. This 'competition' has resulted in a substantial change in the thoracic workload of general surgery and vice versa, and has also been partly responsible for the tendency ofphysicians and general surgeons to perform fibreoptic endoscopy (bronchoscopy, oesophagoscopy) under local anaesthesia whereas previously rigid endoscopy had belonged exclusively to the thoracic surgeon4. In the USA it is difficult to determine how many certified thoracic surgeons actually practice thoracic surgery exclusively. Up to the beginning of 1980s there were 2063 American thoracic surgeons, a ratio of approximately one thoracic surgeon per 100 000 population which was five times the corresponding ratio in UK5. Further evidence of the 'continuous competition' comes from the work of Adkins and Orthner which showed that almost 20% ofthe thoracic surgical procedures are performed by non-certified thoracic (eg general) surgeons in the USA6. In addition, nearly two-thirds of the American thoracic surgeons have a secondary specialty, general surgery being the most common (approximately 50%), with cardiac or vascular surgery comprising the majority of the rest7. Corresponding percentages are not available for the UK but from our own figures it can be seen that although there are many similarities, there are some striking differences, particularly in the overall development of the specialty. In Figure 1 it can be seen that of the total patients studied only 44.9% (5146) were admitted for thoracic problems, this being approximately half the corresponding figure for surgeons in the USA6. This may reflect the lack offormal certification in the UK which allows a greater flexibility in admission patterns largely influenced by personal preference on behalf of the surgeon5. This is again in stark contrast to the USA where the overall Board certification rate of thoracic surgeons is the highest (90%o) of any surgical specialty7. Thus whilst clear differences obviously exist between the practice of thoracic surgeons in the UK and the USA in respect of working practice, the distribution ofthoracic disease has many similarities. During the first two periods ofthe study pulmonary tuberculosis and pulmonary and intrapleural sepsis constituted the majority of the workload of the thoracic surgeon (Figures 2-4). These figures also 10 8
F
v Male Female
'80
'82
Year
Figure 2. Distribution of tuberculosis between 1963 and 1982
485
486
Journal of the Royal Society of Medicine Volume 84 August 1991
10 r
24 r
E
Male
D
Female
20 -
8 '
:
16
,, 1 2
4 !t
8
I;
4
2
11964
'66
'68
'l0
Y172 Year
74
176
'T8
'80
L 182
Figure 3. Incidence of lung abscess between 1963 and 1982
demonstrate the impact of the introduction of antibiotics on the incidence of lung abscess and the natural history of empyema, which has been entirely altered. In combination with antibiotics, effective chemotherapy, BCG vaccination and environmental developments have also drastically reduced the incidence of pulmonary tuberculosis and consequently secondary infectious problems2. Lung cancer remains by far the most common fatal cancer in British men and currently causes approximately 35 000 deaths a year in England and Wales8. The overall mortality is still 80% within a year of diagnosis and nowadays surgical treatment of lung cancer has become almost the raison d'etre of the thoracic surgeon, reflected in the fact that 95% of lung resections are carried out for lung carcinoma9. The most striking feature ofthis fatal condition is the change in incidence of the disease between the sexes. In Figure 5 it can be seen that lung cancer was substantially more common in men during the late 1960s with a peak in women during the next decade. This difference in sex incidence is consistent with the effects of smoking which became popular among women later than among men8. Unfortunately, despite great improvements in the availability of specialized anaesthetists and radiographic and pathological diagnostic facilities, there have been no improvements in the survival rates following surgery and mortality figures have remained static over the last 30-40 years. This is supported by the findings of Bates (who studied 2430 patients treated from 1950 to 1978) and Belcher (8781 patients operated on for lung carcinoma between 1949 and 1980)10,11, whose figures show that the disease process itself is the dominant factor influencing the outcome of treatment. This lack of improvement for primary lung carcinoma contrasts with the long-term survival of patients who undergo lung surgery for metastatic malignant disease of the lung. In these cases provided that the EMPYEMA 24
go Male
20
F]Female
H
11/4
1963 4
5 6
7
8
9 1970 1
2 3
4
5
6
7
8
9 198
1
2 3
Figure 5. Distribution oflung carcinoma between 1963 and 1982
primary tumour has been completely removed and where there is no evidence of other metastatic spread, there is a 33% 5-year survival rate'2. There have been similar changes in the incidence of chest trauma and foreign bodies in our series, but the underlying reasons for this are probably quite different. Originally (up to the mid-1970s) the majority of -these patients were referred to general surgeons, but more recently an increasing number are being treated by thoracic surgeons. This has been facilitated by the recent establishment of properly organized regional cardiothoracic units, that ensures that the patient with major thoracic problems will be seen and treated immediately by an experienced thoracic surgeon8. Finally the distribution of general surgical conditions including non-malignant oesophageal conditions, oesophageal tumours, abdominal herniae, breast disease, genitourinary problems and other miscellaneous general surgical conditions, has also been influenced by these changes. They serve to further emphasize the (as is popularly thought) 'competition' between general and thoracic surgeons. This is nowhere keener than in the field of oesophageal surgery. General surgeons operated increasingly on oesophageal disease during the second half of the surveyed 20-year period and this was probably responsible for the majority of the falls in referrals to thoracic surgeons. This is due in part to the emergence of a number of general surgeons with ..a special interest in oesophageal diseases, but also to general improvements that have occurred in anaesthesia and supportive care allowing major surgery to be performed in an increasing variety of surgical units'3. The introduction of transhiatal oesophagectomy and the recently reported remarkable 5-year survival rates (after en-bloc resection of oesophageal tumours of 20-34.7%) have led to a further shift in the distribution of oesophageal
surgery'4"5 It is clear from our study that general surgeons are increasingly undertaking major procedures,
16 12 8 4
Year
Figure 4. Incidence of empyema between 1963 and 1982
previously the domain of the thoracic surgeons. This increase has taken place progressively over the last 20-30 years and probably -reflects a number of influences including the fact that many of the cardiothoracic surgeons (at least of the younger generation) have been attracted by the striking evolution of cardiac surgery, leaving more space for thoracic conditions to be dealt with by general surgeons with a special interest.
Journal of the Royal Society of Medicine Volume 84 August 1991 References 1 Paulson DL. A time for assessment. J Thorac Cardiovasc Surg 1981;82:163-8 2 English TAH. Future of cardiothoracic surgery. Thorax 1979;34:443-6 3 Allison PR, Temple LJ. The future of thoracic surgery. Thorax 1966;21:99-103 4 Mitchell DM, Emerson CJ, Collyer J, Collins JV. Fibreoptic bronchoscopy: ten years on. BMJ 1980;281:360-3 5 Ellis FH Jr. Education of the thoracic surgeon. Thorax 1980;35:405-14 6 Adkins PC, Orthner HF. The society ofthoracic surgeons manpower survey for 1976: a summary. Ann Thorac Surg 1979;28:407-12 7 Bloom BS, Nickerson RJ, Hauck WW Jr, Peterson OL. Thoracic surgeons and their surgical practice. J Thorac Cardiovasc Surg 1979;78:167-74 8 Coggon D, Acheson ED. Trends in lung cancer mortality. Thorax 1983;38:721-3
Forthcoming events
3rd Annual Meeting of the British Sleep Society 1-3 September 1991, Worcester College, Oxford Further details from: Dr J Stradling, Osler Chest Unit, Churchill Hospital, Headington, Oxford OX3 7LJ (Tel: 0865 225236; Fax: 0865 225221) Good Clinical Practice: A Basic Course 5-6 September 1991, National Heart & Lung Institute, London Further details from. Christine Bull, Rostrum, Lewis House, 1 Mildmay Road, Romford RM7 7DA (Tel: 0708 745042; Fax: 0708 725413) 7th IUVDT Regional Conference on Sexually Transmitted Diseases 5-7 September 1991, Kuala Lumpur, Malaysia Further details from: Conference Secretariat, Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 59100 Kuala Lumpur, Malaysia (Tel: 03 7502264; Fax: 603 7557740) Introduction to Regulatory Affairs 9-10 September 1991, Royal Society of Medicine, London Further details from: (see entry for 5-6 September 1991)
Uveitis & Retina Frontiers: Diagnostic, Medical and Surgical Approaches 13-15 September 1991, Carmel Valley Ranch Resort, California Further details from: University of California, Extended Programs in Medical Education, Room LS-105, San Franciso, CA 94143-0742, USA (Tel: 415 476-4251; Fax: 415 476-0318)
Schizophrenia: Neurobiology, Clinical Aspects and Trial Designs 16-17 September 1991, Royal Society of Medicine, London Further details from: (see entry for 5-6 September 1991) Detection & Management of Fraud in Clinical Research 19-20 September 1991, National Heart & Lung Institute, London Further details from: (see entry for 5-6 September 1991)
9 Smith RA. Development of lung surgery in the United Kingdom. Thorax 1982;37:161-8 10 Bates M. Surgical treatment of bronchial carcinoma. Ann R Coll Surg Engl 1981;63:164-7 11 Belcher JR. Thirty years of surgery for carcinoma ofthe bronchus. Thorax 1983;38:428-32 12 Marks P, Ferrag MZ, Ashraf H. Rationale for the surgical treatment of pulmonary metastases. Thorax 1981;36:679-82 13 Collis JL. The history of British oesophageal surgery. Thorax 1982;37: 795-802 14 Wong J. Transhiatal oesophagectomy for carcinoma of the thoracic oesophagus. Br J Surg 1986;73: 89-90 15 Hennessy TPJ. Choice of treatment in carcinoma of the oesophagus. Br J Surg 1988;75:193-4
(Accepted 20 November 1990)
Look After Your Heart International Conference: Collaboration, Co-operation and Community Participation 19-20 September 1991, London Further details from: Judy Berry, Health Education Authority, Hamilton House, Mabledon Place, London WC1H 9TX (Tel: 071-383 3833; Fax: 071-387 0550) Current Issues in Infection & Antimicrobial Therapy 24-25 September 1991, National Heart & Lung Institute, London Further details from: (see entry for 5-6 September 1991) Colposcopy 24-25 September 1991, Royal College of Obstetricians & Gynaecologists, London Further details from: Postgraduate Education Department, The Royal College of Obstetricians and Gynaecologists, 27 Sussex Place, Regent's Park, London NW1 4RG (Tel: 071-262 5425, ext 207) Monitoring of Orthopaedic Implant Biomaterials: Microelectronics Challenge 25-28 September 1991, Brussels Further details from: F Burny, Service OrthopedieTraumatologie, Universith Libre de Bruxelles, Route de Lennik 808, B 1070 Bruxelles, Belgium (Tel: 2-526 36 45; Fax: 2-520 35 56) Transitional and Community Care of Patients with Neurological Disabilities 27 September 1991, Oswestry, Shropshire Further details from: Erica Wilkinson, Institute of Orthopaedics, The Robert Jones & Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire (Tel: 0691 655311 ext. 3392) Initial Total Care of the Patient with Spinal Injuries 28 September 1991, Oswestry, Shropshire Further details from: (see previous entry) Autumn Meeting of the British Association of Oral and Maxillofacial Surgeons 27-29 September 1991, Harrogate Conference Centre Further details from: John C Lowry, Honorary Secretary, British Assciation of Oral and Maxillofacial Surgeons, Royal College of Surgeons of England, 35/43 Lincoln's Inn Fields, London WC2A 3PN MEDART International: First World Congress on Arts Medicine 29 September to 4 October 1991, The Hague, The Netherlands Further details from: Hoboken Congress Organization, Erasmus University, POB 1738, 3000 DR Rotterdam, The Netherlands (Tel: 31(0)10408 7881; Fax 31(0)10-436 7271) continued on p492
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