Print
E-Mail
Facebook
Twitter
SharethisThe prognosis of the future of surgical disciplines like cardiac surgery and surgery of the lung and chest is not easy in times where progress can be very rapid, conditions of health policy may change dramatically and the professional environment tends to be revolutionized. Experts for judging the future reliably are called prophets. In the past I have proven to have little talents in that direction. Some twelve years ago my lone secretary changed her electric typewriter with a one-line text display to our first computer, but seemed to need even more overtime than before, which led me to conclude that electronic-data management would take a long time to develop, and therefore would not affect my professional life importantly. That judgment error has been corrected since, and the CTSnet is a gleaming example of just how much can be accomplished. A second error was my underestimation of videoassisted surgery, which seemed to me rather unsafe, time-consuming and compromising for the education and training in classical surgery of the chest. I had some sympathy with that phrase of a prominent heart surgeon: "Chopstick surgery under forever-oscopy".
The lessons learned are that there is little which cannot be anticipated, and the future to some degree can be influenced by ourselves. Optimistic individuals will believe in these maxims, pessimistic ones will not. I will try to be realistic.
My first consideration is directed towards the future development of the required volume in cardiac surgery and general thoracic surgery respectively. Obviously, the tremendous expansion in cardiac surgery was closely related to the prevalence of coronary heart disease and the ability to apply surgical palliation with ever- decreasing risk. About 800.000 coronary bypass procedures are presently performed every year worldwide, and an additional similar number of patients receives catheter dilatation and stenting. In spite of programs designed to treat hypertension and hypercholesteremia, coronary heart disease is likely to be with us for quite a while. The incidence of pathological obesity is on the increase in the United States and parts of Europe. Smoking is reduced in males but is increasing in females, thus more women will likely require revascularization and lung cancer surgery. Smoking is a pervasively common habit for a huge number of poor and even malnourished people throughout the world. Should the economical development in second and third world regions improve over the next decades, it seems realistic to assume there will be an even greater need for cardiac surgery.
One question that remains is whether new treatment methods will compete with surgery. Neoangiogenesis, with the use of heparin-binding growth factors, has been applied intramyocardially in clinical studies in conjunction with bypass grafting with satisfying clinical results. It is imaginable that this could be done with a catheter technique via the intraventricular or the coronary artery route. The use of recombinant human growth factor seems to have long-lasting effects on myocardial vascularity. However, there is some concern about the potential risk of unadvertedly supporting angiogenesis in occult tumors, and hence increasing cancer rates as a side effect of such treatment. The costs are difficult to estimate, but I would not be surprised if patients with chronic coronary artery disease in a few years will be candidates for such treatment, thus substantially reducing the need for surgery.
Will robotic surgery replace the cardiac surgeon? Although in the reality of contemporary industrial production computerized design can be transformed to computerized construction, I do not think that in the near future it will be realistic to assume that in cardiac surgery robotic instrumentation will reduce surgical manpower significantly.
What about general thoracic surgery? In comparison to cardiac surgery, it seems to me much more difficult to estimate the present worldwide volume. Even on a national basis exact figures are not available because in perhaps 30% of patients the thoracic procedures are performed by general surgeons. Of that volume, half are cases of malignant diseases. I believe that measures of prevention in highly developed countries will not reduce the incidence of malignancy for at least ten years. The development of anti-cancer drugs remains a prominent target of science. Will it lead to the replacement of surgery in the future, or will it, rather, lead to a increase in the number of patients who are at present considered inoperable then becoming candidates for surgery? The incidence of cancer of lung and bronchus shows an enormous variation geographically and by race. According to OLSEN, head of the Danish Cancer Society, the crude rate of lung cancer among the male population within the European Community is 88 per 100,000 with a variation between 133 in Belgium and 20 in Portugal, the age-standardized incidence rates being 91.8 and 23.8 respectively. Worldwide, the annual age-adjusted rate per 100,000 population is less than 25 in countries like Algeria, Equador, India, and others, 80 for white males and 122 for black males in the United States. Probably, some of these figures are not very reliable, in particular in overpopulated areas, but also in countries like Germany where exact and valid cancer data are missing due to the lack of an obligatory registry. The frequency of demand for general thoracic surgical procedures depends not only on the incidence of diseases but also on the availability of resources. Costs of individual treatment are much lower than for cardiac surgery, at least for patients with early stage cancer and non-malignant disease. I would postulate, therefore, that demands for general thoracic surgery will increase in less industrialized countries but will remain rather stable in highly developed ones.
The future of cardiothoracic surgery is also influenced by health policy and financial resources in countries both rich and poor. We are now facing a world-wide proliferation of bureaucracy in medicine, the argument being that it will provide better oversight, quality- and cost-control. It is estimated that the costs of developing and running such systems for hospitals alone will consume about 5% of their total budget. Medical doctors salaried by the insurance companies are exerting increasing control over physicians in clinical practice, and are sharing in an increasing proportion of the health insurance payment. My prognosis is that this system will prevail in most Western countries. It will not affect standard procedures as much, but it might hamper the present trend to include older age group patients, or to offer surgery to patients with advanced cancers. I am skeptical that the medical profession alone will be able to change the situation. Society as a whole will have to decide whether patients must surrender and accept such a system.
The future of cardio-thoracic surgery is closely related to the quality and structure of postgraduate education. Specialization has led to major progress and improvement of results. The advantages of the routine accumulation of experience are obvious. If, however, specialization occurs too early, those advantages might be counterbalanced by the adverse effects of (ophthalmologically speaking) annular scotoma. Whereas the comprehensive curriculum conceived by the Thoracic Surgery Directors Association provides broad knowledge in the whole field of cardio-thoracic surgery, in many European countries the demands of knowledge in cardiac surgery for the general thoracic surgeon are minimal, and vice versa. I am confident that this will change as soon as general thoracic surgery has reached European-wide recognition as a distinct field of medical science and practice. It will then be possible to improve training in areas at present lacking in competence. We have some instruments available already: the European Board examinations and the annual scientific meetings held in the United States, Japan, and other countries, and this current year in Lisbon, Portugal as a Joint Meeting of the European Association for Cardio-Thoracic Surgery and the European Society of Thoracic Surgeons. My belief is that strengthening this partnership between thoracic and cardiac surgeons to our patients' advantage. Here I do see an area which can be effectively influenced by ourselves alone. Well-educated and well-trained experts in general thoracic surgery seem to be lacking in some European countries presently. Considering our humanitarian commitment for the still-less developed areas of this world and our mandate supporting human solidarity, it is obvious that prompt action must be taken to correct this shortage.
