Cardiothoracic surgery

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(Redirected from
Thoracic surgery
)

Cardiothoracic Surgeon
Cardiothoracic surgeon performs an operation.
Occupation
Names
  • Doctor
  • Surgeon
Occupation type
Specialty
Activity sectors
Medicine, Surgery
Description
Education required
Fields of
employment
Hospitals, Clinics

Cardiothoracic surgery is the

mediastinal
structures.

In most countries, cardiothoracic surgery is further subspecialized into cardiac surgery (involving the heart and the great vessels) and thoracic surgery (involving the lungs, esophagus, thymus, etc.); the exceptions are the United States, Australia, New Zealand, the United Kingdom, India and some European Union countries such as Portugal.[1]

Training

A cardiac surgery

pediatric cardiac surgery, cardiac transplantation, adult-acquired heart disease, weak heart issues, and many more problems in the heart.[citation needed
]

Australia and New Zealand

The highly competitive Surgical Education and Training (SET) program in Cardiothoracic Surgery is six years in duration, usually commencing several years after completing medical school. Training is administered and supervised via a bi-national (Australia and New Zealand) training program. Multiple examinations take place throughout the course of training, culminating in a final fellowship exam in the final year of training. Upon completion of training, surgeons are awarded a Fellowship of the

]

Canada

Historically, cardiac surgeons in Canada completed general surgery followed by a fellowship in CV / CT / CVT. During the 1990s, the Canadian cardiac surgery training programs changed to six-year "direct-entry" programs following medical school. The direct-entry format provides residents with experience related to cardiac surgery they would not receive in a general surgery program (e.g. echocardiography, coronary care unit, cardiac catheterization etc.). Residents in this program will also spend time training in thoracic and vascular surgery. Typically, this is followed by a fellowship in either Adult Cardiac Surgery, Heart Failure/Transplant, Minimally Invasive Cardiac Surgery, Aortic Surgery, Thoracic Surgery, Pediatric Cardiac Surgery or Cardiac ICU. Contemporary Canadian candidates completing general surgery and wishing to pursue cardiac surgery often complete a cardiothoracic surgery fellowship in the United States. The Royal College of Physicians and Surgeons of Canada also provides a three-year cardiac surgery fellowship for qualified general surgeons that is offered at several training sites including the University of Alberta, the University of British Columbia and the University of Toronto.[citation needed]

Thoracic surgery is its own separate 2–3 year fellowship of general or cardiac surgery in Canada.

Cardiac surgery programs in Canada:[citation needed]

United States

Surgeon operating

Cardiac surgery training in the

thoracic surgery and called cardiothoracic surgery or thoracic surgery. A cardiothoracic surgeon in the U.S. is a physician who first completes a general surgery residency (typically 5–7 years), followed by a cardiothoracic surgery fellowship (typically 2–3 years). The cardiothoracic surgery fellowship typically spans two or three years, but certification is based on the number of surgeries performed as the operating surgeon, not the time spent in the program, in addition to passing rigorous board certification tests. Two other pathways to shorten the duration of training have been developed: (1) a combined general-thoracic surgery residency consisting of four years of general surgery training and three years of cardiothoracic training at the same institution and (2) an integrated six-year cardiothoracic residency (in place of the general surgery residency plus cardiothoracic residency), which have each been established at many programs (over 20).[3]
Applicants match into the integrated six-year (I-6) programs directly out of medical school, and the application process has been extremely competitive for these positions as there were approximately 160 applicants for 10 spots in the U.S. in 2010. As of May 2013, there are 20 approved programs, which include the following:

Integrated six-year Cardiothoracic Surgery programs in the United States:[citation needed]

The American Board of Thoracic Surgery offers a special pathway certificate in congenital cardiac surgery which typically requires an additional year of fellowship. This formal certificate is unique because congenital cardiac surgeons in other countries do not have formal evaluation and recognition of pediatric training by a licensing body.

Cardiac surgery

Cardiac surgery
Two cardiac surgeons performing a cardiac surgery known as coronary artery bypass surgery. Note the use of a steel retractor to forcefully maintain the exposure of the patient's heart.
ICD-9-CM3537
MeSHD006348
OPS-301 code5-35...5-37

The earliest operations on the

post mortem proved to be mediastinitis on the third postoperative day.[6][7] The first successful surgery of the heart, performed without any complications, was by Ludwig Rehn of Frankfurt, Germany, who repaired a stab wound to the right ventricle on September 7, 1896.[8][9]

Surgery in

Blalock-Taussig shunt creation, closure of patent ductus arteriosus) became common after the turn of the century and falls in the domain of cardiac surgery, but technically cannot be considered heart surgery. One of the more commonly known cardiac surgery procedures is the coronary artery bypass graft (CABG)
, also known as "bypass surgery."

Early approaches to heart malformations

In 1925 operations on the heart valves were unknown. Henry Souttar operated successfully on a young woman with mitral stenosis. He made an opening in the appendage of the left atrium and inserted a finger into this chamber in order to palpate and explore the damaged mitral valve. The patient survived for several years[10] but Souttar's physician colleagues at that time decided the procedure was not justified and he could not continue.[11][12]

Cardiac surgery changed significantly after

Russell Brock at Guy's Hospital all adopted Souttar's method. All these men started work independently of each other, within a few months. This time Souttar's technique was widely adopted although there were modifications.[11][12]

In 1947

Fallot's Tetralogy. Many thousands of these "blind" operations were performed until the introduction of heart bypass made direct surgery on valves possible.[11]

Open heart surgery

Open heart surgery is a procedure in which the patient's heart is opened and surgery is performed on the internal structures of the heart. It was discovered by

Aleksandr Aleksandrovich Vishnevskiy conducted the first cardiac surgery under local anesthesia.[citation needed
]

Surgeons realized the limitations of hypothermia – complex intracardiac repairs take more time and the patient needs blood flow to the body, particularly to the

heart-lung machine'. John W. Kirklin at the Mayo Clinic in Rochester, Minnesota started using a Gibbon type pump-oxygenator in a series of successful operations, and was soon followed by surgeons in various parts of the world.[citation needed
]

Nazih Zuhdi performed the first total intentional hemodilution open heart surgery on Terry Gene Nix, age 7, on February 25, 1960, at Mercy Hospital, Oklahoma City, OK. The operation was a success; however, Nix died three years later in 1963.[13] In March, 1961, Zuhdi, Carey, and Greer, performed open heart surgery on a child, age 3+12, using the total intentional hemodilution machine. In 1985 Zuhdi performed Oklahoma's first successful heart transplant on Nancy Rogers at Baptist Hospital. The transplant was successful, but Rogers, who had cancer, died from an infection 54 days after surgery.[14]

Modern beating-heart surgery

Since the 1990s, surgeons have begun to perform "

endoscopic vessel harvesting (EVH).[citation needed
]

Some researchers believe that the off-pump approach results in fewer post-operative complications, such as postperfusion syndrome, and better overall results. Study results are controversial as of 2007, the surgeon's preference and hospital results still play a major role.[citation needed]

Minimally invasive surgery

A new form of heart surgery that has grown in popularity is

robot-assisted heart surgery. This is where a machine is used to perform surgery while being controlled by the heart surgeon. The main advantage to this is the size of the incision made in the patient. Instead of an incision being at least big enough for the surgeon to put his hands inside, it does not have to be bigger than 3 small holes for the robot's much smaller "hands" to get through.[citation needed
]

Pediatric cardiovascular surgery

Pediatric cardiovascular surgery is surgery of the heart of children. The first operations to repair cardio-vascular[15] defects in children were performed by Clarence Crafoord in Sweden when he repaired coarctation of the aorta in a 12-year-old boy.[16] The first attempts to palliate congenital heart disease were performed by Alfred Blalock with the assistance of William Longmire, Denton Cooley, and Blalock's experienced technician, Vivien Thomas in 1944 at Johns Hopkins Hospital.[17] Techniques for repair of congenital heart defects without the use of a bypass machine were developed in the late 1940s and early 1950s. Among them was an open repair of an atrial septal defect using hypothermia, inflow occlusion and direct vision in a 5-year-old child performed in 1952 by Lewis and Tauffe. C. Walter Lillihei used cross-circulation between a boy and his father to maintain perfusion while performing a direct repair of a ventricular septal defect in a 4-year-old child in 1954.[18] He continued to use cross-circulation and performed the first corrections of tetralogy of Fallot and presented those results in 1955 at the American Surgical Association. In the long-run, pediatric cardiovascular surgery would rely on the cardiopulmonary bypass machine developed by Gibbon and Lillehei as noted above.[citation needed]

Risks of cardiac surgery

The development of cardiac surgery and cardiopulmonary bypass techniques has reduced the mortality rates of these surgeries to relatively low ranks. For instance, repairs of congenital heart defects are currently estimated to have 4–6% mortality rates.

neurocognitive deficits attributed to cardiopulmonary bypass is known as postperfusion syndrome, sometimes called "pumphead". The symptoms of postperfusion syndrome were initially felt to be permanent,[22] but were shown to be transient with no permanent neurological impairment.[23]

In order to assess the performance of surgical units and individual surgeons, a popular risk model has been created called the EuroSCORE. This takes a number of health factors from a patient and using precalculated logistic regression coefficients attempts to give a percentage chance of survival to discharge. Within the UK this EuroSCORE was used to give a breakdown of all the centres for cardiothoracic surgery and to give some indication of whether the units and their individuals surgeons performed within an acceptable range. The results are available on the CQC website.[24] The precise methodology used has however not been published to date nor has the raw data on which the results are based.[citation needed]

Infection represents the primary non-cardiac complication from cardiothoracic surgery. Infections can include mediastinitis, infectious myo- or pericarditis, endocarditis, cardiac device infection, pneumonia, empyema, and bloodstream infections. Clostridium difficile colitis can also develop when prophylactic or post-operative antibiotics are used.

Post operative patients of cardiothoracic surgery are at risk of nausea, vomiting, dysphagia and aspiration pneumonia.[25]

Thoracic surgery

A pleurectomy is a surgical procedures in which part of the

pleura is removed. It is sometimes used in the treatment of pneumothorax and mesothelioma.[26] In case of pneumothorax, only the apical and the diaphragmatic portions of the parietal pleura are removed.[citation needed
]

Lung volume reduction surgery

Lung volume reduction surgery, or LVRS, can improve the quality of life for certain patients with COPD of emphysematous type, when other treatment options are not enough. Parts of the lung that are particularly damaged by emphysema are removed, allowing the remaining, relatively good lung to expand and work more efficiently. The beneficial effects are correlated with the achieved reduction in residual volume.[27] Conventional LVRS involves resection of the most severely affected areas of emphysematous, non-bullous lung (aim is for 20–30%). This is a surgical option involving a mini-thoracotomy for patients in end stage COPD due to underlying emphysema, and can improve lung elastic recoil as well as diaphragmatic function.[citation needed]

The National Emphysema Treatment Trial (NETT) was a large multicentre study (N = 1218) comparing LVRS with non-surgical treatment. Results suggested that there was no overall survival advantage in the LVRS group, except for mainly upper-lobe emphysema + poor exercise capacity, and significant improvements were seen in exercise capacity in the LVRS group.[28] Later studies have shown a wider scope of treatment with better outcomes.[29]

Possible complications of LVRS include prolonged air leak (mean duration post surgery until all chest tubes removed is 10.9 ± 8.0 days.[30]

In people who have a predominantly upper lobe emphysema, lung volume reduction surgery could result in better health status and lung function, though it also increases the risk of early mortality and adverse events.[31]

LVRS is used widely in Europe, though its application in the United States is mostly experimental.[32]

A less invasive treatment is available as a bronchoscopic lung volume reduction procedure.[33]

Lung cancer surgery

Not all lung cancers are suitable for surgery. The stage, location and cell type are important limiting factors. In addition, people who are very ill with a poor performance status or who have inadequate pulmonary reserve would be unlikely to survive. Even with careful selection, the overall operative death rate is about 4.4%.[34]

In

non-small cell lung cancer staging, stages IA, IB, IIA, and IIB are suitable for surgical resection.[35]

Pulmonary reserve is measured by

diffuse parenchymal lung disease, and the FEV1 exceeds 2 litres or 80% of predicted, the person is fit for pneumonectomy. If the FEV1 exceeds 1.5 litres, the patient is fit for lobectomy.[36]

There is weak evidence to indicate that participation in exercise programs before lung cancer surgery may reduce the risk of complications after surgery.[37]

Complications

A prolonged air leak (PAL) can occur in 8–25% of people following lung cancer surgery.[38][39] This complication delays chest tube removal and is associated with an increased length of hospital stay following a lung resection (lung cancer surgery).[40][41] The use of surgical sealants may reduce the incidence of prolonged air leaks, however, this intervention alone has not been shown to results in a decreased length of hospital stay following lung cancer surgery.[42]

There is no strong evidence to support using

non-invasive positive pressure ventilation following lung cancer surgery to reduce pulmonary complications.[43]

Types

See also

References

  1. ^ "Portuguese Ordem dos Médicos – Medical specialties" (in Portuguese). Archived from the original on 23 January 2012.
  2. ^ "Thoracic Surgery Specialty Description". American Medical Association. Retrieved 28 September 2020.
  3. ^ "Integrated Thoracic Surgery Residency Programs – TSDA". www.tsda.org. Archived from the original on 31 January 2018. Retrieved 8 May 2018.
  4. PMID 9307502
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  5. ^ "Pioneers in Academic Surgery – Opening Doors: Contemporary African American Academic Surgeons". Archived from the original on 29 March 2016. Retrieved 12 February 2016. Pioneers in Academic Surgery, U.S. National Library of Medicine
  6. .
  7. ^ Absolon KB, Naficy MA (2002). First successful cardiac operation in a human, 1896: a documentation: the life, the times, and the work of Ludwig Rehn (1849–1930). Rockville, MD : Kabel, 2002
  8. ^ Johnson SL (1970). History of Cardiac Surgery, 1896–1955. Baltimore: Johns Hopkins Press. p. 5.
  9. ^ Dictionary of National Biography – Henry Souttar (2004–08)
  10. ^ a b c Harold Ellis (2000) A History of Surgery, page 223+
  11. ^ a b Lawrence H Cohn (2007), Cardiac Surgery in the Adult, page 6+
  12. ^ Warren, Cliff, Dr. Nazih Zuhdi – His Scientific Work Made All Paths Lead to Oklahoma City, in Distinctly Oklahoma, November, 2007, p. 30–33
  13. ^ "NDepth: Dr.Nazih Zuhdi, the Legendary Heart Surgeon | Newsok.com". Archived from the original on 25 April 2012. Retrieved 16 April 2012. Dr. Nazih Zuhdi, the Legendary Heart Surgeon, The Oklahoman, Jan 2010
  14. ^ Wikipedia: Coarctation of the Aorta. Coarctation is not cardiac (i.e., heart) but is a narrowing of the aorta, a great vessel near the heart
  15. .
  16. .
  17. PMID 13256320.{{cite journal}}: CS1 maint: multiple names: authors list (link
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  18. S2CID 26116465.{{cite journal}}: CS1 maint: multiple names: authors list (link
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  23. ^ "Heart Surgery in United Kingdom". Archived from the original on 5 November 2011. Retrieved 2011-10-21. CQC website for heart surgery outcomes in the UK for 3 years ending March 2009
  24. ^ Ford C., McCormick D., Parkosewich J., et al. Safety and effectiveness of early oral hydration in patients after cardiothoracic surgery. Am. J. Crit. Care. 2020;29(4):292–300. doi:10.4037/ajcc2020841
  25. ^ Aziz, Fahad (7 January 2017). "Pleurectomy". Medscape. Archived from the original on 6 October 2017. Retrieved 4 October 2017.
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External links