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Ann Thorac Surg 2003;76:S14-S16
© 2003 The Society of Thoracic Surgeons
a Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
* Address reprint requests to Dr Reed, Hollings Cancer Center, 86 Jonathan Lucas St, Charleston, SC 29425, USA
e-mail: reedce{at}musc.edu
Presented at the 50th Anniversary of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 14, 2003.
When one reviews the most recent 25 years of general thoracic history several subjects predominate: video-assisted thoracoscopy (VATS), lung transplantation, lung volume reduction surgery, and the use of new tools in the staging of thoracic malignancies such as positron emission tomography (PET), endoscopic ultrasonography (EUS), and molecular staging. Members of the Southern Thoracic Surgical Association (STSA) as well as invited speakers at the annual meetings have contributed greatly to these subject areas. However a perusal of the program books reveals another important STSA contribution: the appreciation and value of collected reviews and series that highlight the wisdom and experience gained by individuals and institutions. It is this balance that the STSA has and will continue to foster. One remembers when it was claimed that all thoracic surgery would be done by VATS. We have watched the pendulum swing far and in fact it is still swinging but in a less erratic manner. Southern thoracic surgeons have usually heeded the caution of "not throwing out the baby with the bath water." Embracing new concepts and techniques, pushing the limits of known surgical premises but heeding the lessons of past history have brought balance to the annual meetings, to the literature, and to the field of general thoracic surgery.
Although thoracoscopy was first performed by Jacobaeus in 1910, video technology in the late 1980s and early 1990s expanded the operative possibilities for thoracoscopy. "Minimally invasive surgery" has certainly been the buzz word of the past decade. Although controversy remains over its ultimate role in certain procedures, VATS has become a standard component of the general thoracic surgeon's repertoire. Members of the STSA were very early contributors to the role thoracoscopy could play in the diagnosis and treatment of thoracic disease [1–3]. Special mention should be made of the leadership role of Dr Mark Krasna at the University of Maryland whose contributions to the techniques [4], potential complications [5], and expanded use of thoracoscopy [6–8] have been first presented at several STSA annual meetings. Doctor Bradley Rodgers has in a similar fashion contributed to the role of thoracoscopy in pediatric surgery.
As mentioned, the pendulum is still swinging in regard to the utilization of VATS versus open techniques in such procedures as lobectomy, esophagectomy, thymectomy, and complex benign esophageal procedures. It is clear that the learning curve becomes steeper as complexity increases. The results including short- and long-term complications, will undoubtedly be the subject of future STSA general thoracic presentations.
The last 2 decades of the 20th century have seen the renaissance of clinical lung transplantation, initiated by the Toronto Lung Transplant Group. When Dr Alec Patterson and Dr Joel Cooper moved to Washington University in St. Louis, Missouri, they joined an active group of Southern surgeons and institutions contributing to this renaissance. Doctor James Hardy at the University of Mississippi undertook the first lung transplantation in a human in 1962. Bronchial disruption, rejection and infection defeated early attempts at successful lung transplantation. By the end of the 20th century however graft and recipient survival at 1 year after transplantation was 80% to 85% and 5-year survival was 50% at many major centers. That is a remarkable achievement in a short period of time.
The many contributions of Southern surgeons to the field of transplantation are easily seen by reviewing the annual meeting program booklets. Optimization of donor lung survival and function, surgical techniques, and understanding and management of posttransplant complications have been areas of study. The thoracic laboratory at the University of Virginia under the leadership of Dr Irving Kron has consistently worked to identify methods of increasing graft preservation and to understand the mechanisms and outcomes of lung reperfusion injury [9–13]. Transplant surgeons at the University of North Carolina have added significantly to this study of reperfusion injury [14–16] and been leaders in the role of lung transplantation in cystic fibrosis [17]. The transplant laboratory at Washington University has also pursued methods to reduce reperfusion injury [18–20], studied lung transplant rejection [21], and provided us with a highly experienced evaluation of the role of lung transplantation for emphysema [22]. Colleagues at Johns Hopkins University, Bowman Gray, Duke University, University of Texas-Houston, and Vanderbilt University as well as guest speakers at the annual meetings assure an active and continued role of the STSA in the future advancement of lung transplantation.
The concept of lung volume reduction surgery (LVRS) for emphysema was developed by Dr Joel Cooper and colleagues [23], inspired by the earlier work of Brantigan and Mueller [24]. It is probably not exaggerating to say that the reintroduction of this technique has resulted in more controversy than any other subject in general thoracic surgery for the past 25 years. Doctor Cooper gave a special presentation to the STSA in 1995 and Dr Joseph Miller and associates [25] confirmed at this meeting the short-term results. In carefully selected patients LVRS by the median sternotomy approach using the stapling-excision technique is a safe and reasonably efficacious procedure in the treatment of nonbullous end-stage emphysema with "target" areas. Controversies have included selection criteria, surgical approach, unilateral versus bilateral procedures, and expansion of the operation to diffuse emphysema without target areas.
Although only approximately 15% of patients were suitable for Cooper's group, patients and physicians welcomed a surgical procedure for a life-threatening illness and LVRS utilization and research increased dramatically in a matter of a few years. Although favorable results were reported, increasing controversy over the benefits, risks, and costs led Medicare in early 1996 to proclaim LVRS as investigational and to discontinue reimbursement. The natural history of patients suitable for LVRS but denied surgery was reported to the STSA in 1997 [26] and the controversy was fueled. Within the atmosphere of debate between the legitimacy of randomized clinical trials versus well-designed observational studies to assess a new treatment modality, HCFA and the National Institutes of Health joined forces to establish the National Emphysema Treatment Trial (NETT). The results of this trial have been publicized this year [27] but an end to controversy is not easily foreseen.
The STSA being from a part of the country with higher than average incidence and mortality rates for lung and esophageal cancer, contributions to the diagnosis, staging, and treatment of thoracic malignancies has continued to highlight STSA meetings. The use of positron emission tomography (PET) to identify malignant nodules was presented by the Duke group in 1994 [28]. Endoscopic ultrasonography (EUS) to stage esophageal cancer has become the most precise tool presently available and its use was presented to the STSA in 1991 by guest Dr Thomas Rice [29]. The Charleston group at the Medical University of South Carolina has extended knowledge of its use with a number of contributions to the literature [30, 31] and shown that the addition of fine-needle aspiration (FNA) has allowed histologic confirmation of positive celiac lymph nodes, a very poor prognostic finding. The same group of investigators has also utilized EUS/FNA for the staging of mediastinal lymph nodes in nonsmall cell lung cancer (NSCLC) [32]. The addition of VATS in staging lung cancer [33] and the use of thoracoscopy/laparoscopy in staging esophageal cancer [8] have been presented by STSA members. The combination or "fusion" of new technology (PET) with old (CT scan) promises even more precise staging [34]. The role of molecular biological staging in lung cancer [35, 36] and esophageal cancer [37] has been pioneered by Dr David Harpole and colleagues from Duke University. It is predicted that molecular tools will become increasingly important in identifying occult metastases, patients at increased risk of recurrence, and predicting chemoresistant tumors. Future studies will confirm, expand, and clarify the role of molecular markers in the general thoracic surgeon's armamentarium against thoracic malignancies.
Esophageal cancer has been an abiding interest of Southern surgeons. It is rare that a paper on this cancer has not been presented at each meeting. Although subject matter has included surgical approach, patient selection, feasibility, and outcome of induction therapy, the importance of Barrett's esophagus to the rise in adenocarcinoma, methods of palliation, and improvements in staging, it may be fair to say that philosophy still reigns over science. It is the relatively low number of new cases seen at single institutions and differing philosophies that hinder advancement in this disease. Southern thoracic surgeons could become the vanguard of collaborative efforts to more rigorously study esophageal cancer in the new century.
The STSA has always sought balance, a balance between education and social interaction at its meetings, a balance between debate and collegiality, a forum for new ideas without forgetting the value of past experience. For the previous 25 years and, it is hoped, at meetings in the new century the wisdom and experience of leaders in general thoracic surgery will continue to find a forum. Good reviews allow us to share the insight of an individual or institution with years of experience in a specific disease or technique, to understand where we have come and still must go, to decide whether more rigorous studies are needed to complement observational data, and to appreciate the breadth of our field. Pertinent reviews have included the following subjects: malignant neoplasms of the mediastium [38, 39], tracheal resection [40], bronchial adenomas [41], bronchial carcinoids [42], sternal resection and reconstruction [43, 44], chest wall resection and reconstruction [45], treatment of the thoracic outlet syndrome [46], palliative management of malignant air way disease [47], superior sulcus tumor [48], and the use of the Eloesser flap [49]. Although retrospective and perhaps anecdotal, there are lessons to be learned from each of these reviews.
General thoracic surgeons are proud, passionate, and occasionally irascible individuals. During discussions at the STSA meetings, debate and "potshots" are welcome. Yet it would be remiss not to emphasize another enduring feature of the STSA: its welcome and encouragement of presenters who are residents or young faculty. The more relaxed and collegial atmosphere is conducive to new authors. The STSA will continue to be a forum for many future leaders of general thoracic surgery.
References
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