Seminars in Thoracic and Cardiovascular Surgery

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The Case Against Superspecialization in Surgery

Jean Bachet

There is no need to like the coming world to see it coming. François-René Vicomte de Chateaubriand During the second half of the 20th century important changes occurred in the practice of surgery. General surgery gave way to specialties focused on one system (gastrointestinal, orthopedic, neurologic, thoracic, cardiac, vascular surgeries, etc). Subspecialties were formed rapidly inside those specialties. In cardiac surgery we could first observe the separation between adult and congenital surgery. Then within adult surgery we saw the appearance of subspecialties associated with one anatomical element (valves, coronary arteries, great vessels, etc), a pathophysiological disorder (rhythm disturbances, cardiac failure, myocardial ischemia, etc), or a particular technical approach (minimally invasive surgery, video-assisted and robotic techniques, and so on). This arborescence seems to be endless. Indeed, we presently see cardiac surgeons who dedicate their whole practice to only one technique or to only one particular function of the cardiovascular system.

The Case Against Superspecialization in Surgery

Sreekumar Subramanian, Friedrich W. Mohr

If the splintering and fragmentation of surgery continues to the end that an established surgeon, whether in the academic arena or in community surgery, addresses himself to the acquisition of mastership of a few operations, certainly he will do these operations better than the wide ranging surgical generalist … If the surgical specialist is to dominate the scene completely, the future advance of surgery in my opinion will be retarded. Owen Wangensteen (American surgical pioneer), 1972

Citius Altius Fortius: A Case for Superspecialization

Paul Sergeant, Gregory Sergeant

Citius, Altius, Fortius (Faster, Higher, Stronger). It was carved in stone at the main entrance of the Lycée Albert Legrand and later cited by Father Dideon and Baron de Coubertin to eulogize the human ambition to excel. Finally it became the official motto of the Olympic Games. Citius, Altius, Fortius could be impersonated by Mark Cavendish, Samuel Sanchez, and Thor Hushovd, winners of different jerseys or stages at the Tour de France 2011. All three are brilliant cyclists; all three ride on similar bikes, but they differ in anatomy, attitude, and mental and physical skills. Their career-long training and race-specific preparation were also totally different. Their superspecialization allowed them to achieve top performances, but nevertheless, the Tour de France was won by the Australian Cadel Evans, who was up with the best in flat and mountain stages as well as time trials. These 4 riders are perfect metaphors in favor and against superspecialization.

Ex Vivo Lung Perfusion and Extracorporeal Life Support in Lung Transplantation

Bryan A. Whitson, Jonathan D'Cunha

Normothermic ex vivo lung perfusion and extracorporeal life support have re-invigorated lung transplantation.

Is Laparoscopic Heller Myotomy Superior to Pneumatic Dilation to Treat Achalasia?

Toshitaka Hoppo, Blair A. Jobe

Achalasia is a primary esophageal motility disorder that is characterized by the inability of the lower esophageal sphincter to relax and by absence of esophageal body peristalsis, causing dysphagia, chest pain, and regurgitation of undigested food. The goal of treatment is to eliminate dysphagia by opening the lower esophageal sphincter, while preventing gastroesophageal reflux. The currently available treatment options include injection of botulinum toxin at the esophagogastric junction, endoscopic pneumatic dilation, and laparoscopic Heller myotomy (LHM); all therapeutic approaches are palliative and centered on relief of esophageal outlet obstruction. With the widespread acceptance of minimally invasive surgical approaches to diseases of the upper abdomen, LHM combined with a partial antireflux procedure has been most commonly performed and is considered by many to be superior to pneumatic dilation. Although numerous studies have been conducted to compare LHM with pneumatic dilation, publication bias and heterogeneity in technique coupled with the relative rarity of achalasia have led to inadequately powered studies and confusion among providers regarding the optimal approach.

A Primer of High-Resolution Esophageal Manometry

Thomas W. Rice, Steven S. Shay

High-resolution esophageal manometry (HRM) is a quantum evolutionary step beyond conventional manometry, the traditional method of assessing esophageal motility for more than 50 years. HRM advances both pressure measurement and its display. Pressure transducers are placed every centimeter along the manometry catheter (). Sophisticated computer algorithms extrapolate between these measurement points, permitting a continuous, seamless assessment of intraluminal esophageal pressure from pharynx to stomach. The display of intraluminal pressure as a color spectrum on a plot of esophageal position (y-axis) against time (x-axis) produces a pressure topograph of swallowing (). This unique format affords a practical, understandable demonstration of this complex three-variable relationship of swallowing.

Lobectomy for Patients With Limited Lung Function

Sai Yendamuri, Todd L. Demmy

Increasingly, lung cancer is being diagnosed at an early stage. This trend is likely to increase with computerized tomographic screening as a result of the findings of the National Lung Screening Trial. Even in 2011, anatomical lobectomy is the gold standard for curative resection for early lung cancer. However, a significant proportion of patients with early lung cancer have limited lung function that places them at higher risk of complications from lobectomy. This article reviews the existing data for lobectomy in patients with limited lung function.

Long-Term Physiological Consequences of Pneumonectomy

Ever since the first successful pneumonectomy for lung cancer was performed in 1933, a number of largely historical reports have attempted to look at the physiological consequences of this operation in order to define patient long-term functional status. The pertinence of these contributions is, however, limited because most were performed in patients who had their pneumonectomy for benign diseases or were carried out in small and heterogeneous populations. Thus, several surgical myths and beliefs such as phrenic nerve interruption at the time of operation might be desirable, marked hyperinflation of the residual lung is associated with reduced lung function, and patients develop pulmonary hypertension over time and have poor exercise tolerance have persisted over the years. Our findings based on a study of 100 patients evaluated 5 or more years after surgery (mean follow-up time, 9.1 ± 2.8 years [5.0-14.7 years]) show that most patients can adjust to living with only one lung and are thus able to live a near-normal life. Although diaphragmatic paralysis is characterized by significant alterations in respiratory function, hyperinflation of the residual lung is beneficial.

Watchful Waiting for Severe Mitral Regurgitation

Raphael Rosenhek

Watchful waiting is an established treatment strategy for asymptomatic patients with severe organic mitral regurgitation. It is based on indications for surgery that are based on current European Society of Cardiology and American Heart Association/American College of Cardiology guideline recommendations, which are defined by symptom onset, impairment of left ventricular function, and left ventricular enlargement. Excellent outcome is achieved when patients are periodically followed with clinical and echocardiographic examinations and when surgery is performed in expert centers. The strategy is based on the recognition of mitral regurgitation at an early symptomatic stage, avoiding a delayed referral of these patients. There is an ongoing debate about whether surgery should be performed in asymptomatic patients with preserved ventricular function. Ultimately, decision-making needs to be individualized and to take individual patient-related factors and local resources (including the natural history of the disease, the risk of surgery, and the likelihood of successful mitral valve repair) into consideration to obtain an optimal outcome with medical and surgical management.

Adult Congenital Surgery: Current Management

Pascal R. Vouhé

The population of adults with congenital heart disease (CHD) (commonly called grown-ups with congenital heart disease or GUCH) is increasing steadily and exceeds the population of children with CHD already. The specificities of GUCH surgery are multiple and include (1) variety of the anatomo-clinical situations (defects repaired during childhood, malformations either nonoperated or palliated, nonreparable defects), (2) usual multiorgan involvement, and (3) many technical differences related to cardiopulmonary bypass, myocardial protection, and surgical technique. The surgical indications should be taken after a precise evaluation of the risk/benefit ratio on an individual basis; a balanced attitude should be kept between unwise interventionism and excessive waiting policy. It is now agreed that GUCH surgery should be performed in specialized centers with large patient volumes and expertise of both surgical and medical disciplines. Much remains to be done to implement these recommendations and to accumulate experience and evidence-based information to provide optimal outcome.

Minimally Invasive Direct Coronary Artery Bypass: Technical Considerations

Ramachandra C. Reddy

Minimally invasive direct coronary artery bypass grafting (MIDCAB) uses a small anterior left thoracotomy incision and harvesting of the left internal mammary artery with an anastomosis performed to the left anterior descending artery without cardiopulmonary bypass. There is renewed interest in minimally invasive coronary surgery and hybrid revascularization. This article describes a standardized approach that has been consistently successful in our institution.

Another Multidisciplinary Look at Ischemic Mitral Regurgitation

Tomasz A. Timek, D. Craig Miller

Ischemic mitral regurgitation (IMR) continues to challenge surgeons and scientists alike. This vexing clinical entity frequently complicates myocardial infarction and carries a poor prognosis both in the setting of coronary disease and idiopathic dilated cardiomyopathy. Ischemic mitral regurgitation encompasses a difficult patient population that is characterized by high operative mortality, poor long term outcomes, and frequent recurrent insufficiency after standard surgical repair. Yet optimal surgical repair and improved clinical outcomes can only be achieved with better knowledge of the pathophysiology of IMR which is still incompletely understood. The causative mechanism of IMR appears to lie in the annular and subvalvular frame of the valve rather than leaflet or chordal structure leading to such labels as “ischemic,” “functional,” “non-organic,” and “cardiomyopathy associated” being applied in the clinical literature. Although ischemic mitral regurgitation is a prevailing clinical entity, it has not been consistently defined in the literature, contributing to considerable confusion and contradictory results of clinical studies. As the mechanisms of pathophysiology have been better elucidated, novel surgical and interventional strategies have been developed recently to provide better treatment for this difficult patient population. In this review, we undertake a multidisciplinary update of the pathophysiology, classification, and surgical and interventional treatment of ischemic mitral regurgitation in today’s clinical practice.

Surgical Management of Mitral Valve Infective Endocarditis

Charles F. Evans, James S. Gammie

Active mitral valve infective endocarditis is a challenging clinical problem with a high rate of mortality. Surgery is currently performed in more than 40% of patients, and selecting those patients who will benefit from surgical intervention and performing a technically sound operation at the proper time are keys to optimizing outcomes. Moderate-to-severe and severe mitral regurgitation, large, mobile vegetations, paravalvular abscess, embolic events, failure of antibiotic therapy, and infection with a fungal organism are indications for prompt operation. The use of computed tomography imaging is important to determine whether there are noncardiac sources of infection, and transesophageal echocardiography is essential to delineate valvular dysfunction, identify paravalvular abscesses, rule out involvement of other valves, and plan operative therapy. In most cases, surgery should not be delayed because of cerebrovascular emboli. Mitral valve repair is favored over replacement whenever possible, is associated with superior short- and long-term outcomes, and should be possible in most cases. Operative mortality is <10% and 5-year survival is >80%.

Technique for Less Invasive Implantation of Heartmate II Left Ventricular Assist Device Without Median Sternotomy

Anelechi C. Anyanwu

The standard implantation of the Heartmate II left ventricular assist device (LVAD) (Thoratec Inc, Pleasanton, CA) involves a median sternotomy. There are some theoretical advantages to avoiding a median sternotomy in LVAD implantation. Hill et al introduced the concept of implantation of LVADs via a combination of right mini-thoracotomy and left subcostal incision and used this approach to implant the Thoratec paracorporeal LVAD (Thoratec Inc). Gregoric et al subsequently described a less invasive approach for implanting the Heartmate II LVAD without median sternotomy by using a subcostal incision and a right mini-thoracotomy, and they used the approach in 3 patients. With some modifications, we now use this method for routine implantation of the Heartmate II and describe our technique.

Implantation of the HeartWare Left Ventricular Assist Device

Mark S. Slaughter

Left ventricular assist devices (LVADs) are the treatment of choice for advanced heart failure that is refractory to medical therapy for both Bridge to Transplantation and Destination Therapy in appropriately selected patients. The newer continuous flow LVADs are more reliable and durable and have resulted in significant size reduction compared to pulsatile flow LVADs. This “miniaturization” of the LVAD has potential advantages including less surgical trauma for implantation. The HeartWare HVAD is a new continuous flow LVAD, currently in trials, that is designed to be implanted and contained completely within the pericardial space.

Techniques My Way: Introduction

Rafael S. Andrade

The purpose of this section is to shed some light on the technical aspects of sympathetic ablative surgery (SAS) for primary palmar hyperhidrosis (PH) and primary axillary hyperhidrosis (AH). The available literature on this subject can be challenging to interpret because there are no uniform nomenclature and no standardized operative technique.

Sympathetic Ablative Surgery for Palmar and Axillary Hyperhidrosis

Shah-Hwa Chou

Excessive sweating interferes considerably with daily life; the problem has become more serious because of the increasing popularity of electronic devices. This disorder also affects social activities and can ultimately lead to psychological withdrawal. Treatment for this embarrassing condition is in high demand.

Sympathetic Ablative Surgery for Palmar and Axillary Hyperhidrosis

Chien-Chih Lin

Sympathetic ablative surgery (SAS) has been used for more than 50 years to treat a variety of sympathetic disorders. Initially, SAS at the level of T2 was the procedure of choice for palmar hyperhidrosis; however, postoperative reflex sweating was identified as the most common and vexing side effect of this procedure. In 2001, the Lin-Telaranta classification was proposed to explain the mechanism and the route of sympathetic fibers. Under this classification, the procedure of choice for palmar hyperhidrosis is T4 SAS and for axillary hyperhidrosis is T4 and T5 SAS, which lead to excellent symptom control and minimal reflex sweating.

Seminars in Thoracic and Cardiovascular Surgery

Masthead

Officers

Table of Contents

The Case Against Superspecialization in Surgery

The Case Against Superspecialization in Surgery

Citius Altius Fortius: A Case for Superspecialization

Ex Vivo Lung Perfusion and Extracorporeal Life Support in Lung Transplantation

Is Laparoscopic Heller Myotomy Superior to Pneumatic Dilation to Treat Achalasia?

A Primer of High-Resolution Esophageal Manometry

Lobectomy for Patients With Limited Lung Function

Long-Term Physiological Consequences of Pneumonectomy

Watchful Waiting for Severe Mitral Regurgitation

Adult Congenital Surgery: Current Management

Minimally Invasive Direct Coronary Artery Bypass: Technical Considerations

Another Multidisciplinary Look at Ischemic Mitral Regurgitation

Surgical Management of Mitral Valve Infective Endocarditis

Technique for Less Invasive Implantation of Heartmate II Left Ventricular Assist Device Without Median Sternotomy

Implantation of the HeartWare Left Ventricular Assist Device

Techniques My Way: Introduction

Sympathetic Ablative Surgery for Palmar and Axillary Hyperhidrosis

Sympathetic Ablative Surgery for Palmar and Axillary Hyperhidrosis