European perspectives in thoracic surgery

Europe, the old continent, has been the cradle of thoracic surgery from the beginning of the last century: from the failed attempt of the Polish surgeon Block in opening the thorax in 1904 to the following success of Ferdinand Sauerbruch, at the famous institution of von Mikulicz-Radecki, who introduced his method of low pressure ventilation. During the following years many steps leading towards modern thoracic surgery were performed in Europe in all the fields: surgery for tuberculosis and lung cancer, esophageal surgery, surgery of the mediastinum, particularly the thymus; even the most sophisticated techniques like lung volume reduction for emphysema were initially performed here. However, until the early 70s’ no European Society was conceived while on the American side the Society of Thoracic Surgeons and the American Association for Thoracic Surgery were respectively founded in 1964 and 1917.

In 1976 Francisco Paris, with Keyvan Moghissi and Paul Witz set an historical meeting in Valencia and made the first move towards what in the future would have been called the European Thoracic Surgery Club. During the following years Ingolf Vogt–Moykopf explored with enthusiasm the chance to evolve from the structure of a “Club” to a scientific society. This need was initially met in 1986 with the foundation of the European Association for Cardiothoracic Surgery (EACTS), including both cardiac and general thoracic surgeons. However, although the initial steps were successful, it was immediately clear that there was urgency for a better profile of general thoracic surgeons with a dedicated scientific society.

The new, dedicated Society was founded in 1993, during a European Consensus Meeting in Heidelberg, the city of Ingolf Vogt-Moykopf. The ESTS had initially 43 members.

Since then the ESTS grew up faster and faster. It now has a much more complex structure with councilors, officers and trustees, ad hoc committees, working groups, a well structured educational platform, an international data base, a quality control program, and it is strictly linked to the European Board. It now has more than 1,300 members from around the world, including North and South America, Eastern Countries, Asia and Japan.

During the years several activities have been developed from the Society, alone or together with other scientific associations. The numerous working groups have successfully organized meetings, produced guidelines, consensus statements, and, finally, scientific papers (1-4); some information was collected also from surveys among the members (5-7). These groups have been able to coagulate the knowledge of different specialties from allover Europe and the documents they have produced are now the referring statements in many countries (8). The retrospective collection of databases have been able to allow an analysis on large groups that in no other part of the world was possible and the construction od algorithms for data analysis (9). An example is the Thymic Malignancies Group that after a number of retrospective studies has now moved towards a prospective database and the organization of tissue banking. This was possible only with the joined coordination and supervision of many scientific societies together, now leading to a thymic malignancy staging project along with International Thymic Malignancy Interest Group (ITMIG) and International Association for the Study of Lung Cancer (IALSC) (10).

In this setting the database plays obviously an extremely important role. This is one of the pillars of the ESTS and is governed, monitored and organized by a dedicated officer. The number of centers referring patients is growing exponentially and national databases, like the French one, are starting to insert cases increasing the volume of the dataset. An annual report is produced at every annual meeting of the society and a complimentary book (the Silver Book) is offered in that occasion to all the members.

Educational programs are the heart of the activities of the European Society of Thoracic Surgery. The goal of the Society is to improve the quality in all the activities of our specialty: from clinical and surgical management of patients to education, training and credentialing. Education and training is taken care at different levels, from trainees and residents to consultants. A functional Society needs to focus on raising everybody’s ability to comply with evidence–based medicine by involving the most gifted in the mentoring and steering process (11).

The Annual Meeting itself is a good example of how different scientific societies can join their efforts to produce outstanding educational programs. The structure of the Postgraduate course is tailored to involve the delegates in the discussion and in the past years it has been organized along with the American Association for Thoracic Surgery, the Society of Thoracic Surgeons and the Japanese Association for Cardiothoracic Surgery; it has now been restructured to involve also residents. But what is most important, is certainly the strict relationship with other scientific societies, in order to design sessions dedicated to a multidisciplinary approach to different problems: the European Respiratory Society (ERS), the European Association of CardioThoracic Anesthesiologists (EACTA), the European Thoracic Oncology Platform (ETOP), the IALSC, the European Society of Thoracic Radiation Oncology (ESTRO), the European Society of Medical Oncology (ESMO), the Chest Wall International Group, the ITMIG have all been involved.

However, this view may potentially lead to the proliferation of scientific events (meetings, courses, etc.). With this perspective, the organization of a global thoracic surgical network (11) based on strict peer reviewing and past-event audits to verify the appropriateness of the educational outcome could help to prevent this “complication” and is now needed more than ever. With this aim, the ESTS is constantly looking towards the east and the west and always welcomes committed surgeons and Associations to work on the constitution of an international worldwide environment potentially ESTS powered (10).

Beyond the activities within the annual meeting, the ESTS has been able to set different programs within the Educational Platform. Theoretical Courses have been organized in Antalya since 2007; this course, with lectures prepared by more than 70 international members of the faculty, is organized to prepare thoracic trainees for the thoracic exam organized by the European Board. Hands on courses have been set in Elancourt, at the Covidien educational facility. A traveling fellowship is available as well as itinerant courses on specific topics; an Academy for Advanced Surgical Technique is organized in Budapest. The newborn in this field is the ESTS Biology Club Scholarship, organized in conjunction with the Committee for Research and Education (CRE). This scholarship offers a unique program allowing young scientists and clinicians to visit a host unit within Europe to learn or gain insight into a research technique that is not available in the home unit.

Overall, all these activities should be directed to enlighten the path, provide the tools and set the standards for a quality inspired practice in thoracic surgery. The only way to know the future is to invent it ourselves.

Acknowledgements

Disclosure: The author declares no conflict of interest.

References

1. Ruffini E, Detterbeck F, Van Raemdonck D, et al. Tumours of the thymus: a cohort study of prognostic factors from the European Society of Thoracic Surgeons database. Eur J Cardiothorac Surg 2014. [Epub ahead of print]. [PubMed]
2. De Leyn P, Dooms C, Kuzdzal J, et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014;45:787-98. [PubMed]
3. De Leyn P, Lardinois D, Van Schil PE, et al. ESTS guidelines for preoperative lymph node staging for non-small cell lung cancer. Eur J Cardiothorac Surg 2007;32:1-8. [PubMed]
4. Brunelli A, Falcoz PE, D’Amico T, et al. European guidelines on structure and qualification of general thoracic surgery. Eur J Cardiothorac Surg 2014;45:779-86. [PubMed]
5. Ruffini E, Van Raemdonck D, Detterbeck F, et al. Management of thymic tumors: a survey of current practice among members of the European Society of Thoracic Surgeons. J Thorac Oncol 2011;6:614-23. [PubMed]
6. Internullo E, Cassivi SD, Van Raemdonck D, et al. Pulmonary metastasectomy: a survey of current practice amongst members of the European Society of Thoracic Surgeons. J Thorac Oncol 2008;3:1257-66. [PubMed]
7. Rocco G, Rendina EA, Venuta F, et al. The use of sealants in modern thoracic surgery: a survey. Interact Cardiovasc Thorac Surg 2009;9:1-3. [PubMed]
8. Brunelli A, Charloux A, Bolliger CT, et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). Eur Respir J 2009;34:17-41. [PubMed]
9. Brunelli A, Rocco G, Van Raemdonck D, et al. Lessons learned from the European thoracic surgery database: the Composite Performance Score. Eur J Surg Oncol 2010;36 Suppl 1:S93-9. [PubMed]
10. Detterbeck FC, Asamura H, Crowley J, et al. The IASLC/ITMIG thymic malignancies staging project: development of a stage classification for thymic malignancies. J Thorac Oncol 2013;8:1467-73. [PubMed]
11. Rocco G. A view from above. Eur J Cardiothorac Surg 2009;35:385-91. [PubMed]