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Training of European thoracic surgeons is subject to huge variations in terms of length of training, content of training and operative experience during training. Harmonization of training outcomes has been approached by creating the European Board of Thoracic Surgery, which has been accredited by the European Union of Medical Specialists (UEMS); however, a clear description of the content of training is lacking. Building on their recognized experience with curriculum building, task forces of the European Respiratory Society and the European Society of Thoracic Surgery agreed on a joint task force on training in thoracic surgery. The goal of this study is to report on the mission statement developed from the UEMS-driven survey, describe the Delphi method and the observed results and present the first large consensus-based syllabus. The working group is currently working on a description of the curriculum and assessment of learning outcomes. ispartof: EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY vol:54 issue:2 pages:214-220 ispartof: location:AUSTRIA, Innsbruck status: published

OBJECTIVES The literature concerning relations between thoracic surgery and digestive motility is poor. The aim of our study was two-fold: (i) to show a link between thoracic surgery and gastric distension and (ii) between post-operative pneumoniae and gastric distension. METHODS A retrospective analysis was conducted in 262 patients who had undergone a thoracotomy for lung resection between January and December 2007. Transverse diameter of the stomach was measured on chest X-rays performed on Day 0 and on Day 1. Gastric distension was defined as a ratio (R) D1/D0 higher than 1.3 (min: 0.5; max: 4.1). Three groups were defined: Group 1 (absence of distension) R < 1.3; Group 2 (moderate distension) 1.3 ≤ R < 2.3; Group 3 (major distension) R ≥ 2.3. International criteria of the Center of Disease Control were used to define pneumonia. Appropriate statistical tests were carried out. RESULTS There were 73 women (27.9%) and 189 men (72.1%), ages ranged from 20 to 83 years (average: 59.9 years). As for gastric distension, 194 patients (74.04%) constituted Group 1, 53 (20.23%) Group 2 and 15 (5.73%) Group 3. Pneumonectomy significantly increased the incidence of gastric distension on Day 1 (P = 0.04). The side, mediastinal lymphadenectomy and personal medical past history of upper gastro-intestinal tract surgery had no statistically significant influence on the incidence of gastric distension. Univariate analysis showed that patients with gastric distension on D1 had significantly more infectious pneumonia on Day 5 (P < 0.0001): 16 (8.25%) patients in Group 1, vs 14 (26.41%) in Group 2 and 7 (46.67%) in Group 3. Furthermore, on Day 5, 33.33% (n = 8) of pneumectomies had pneumonia, against 12.18% (n = 29) of patients who had undergone another type of surgery (P = 0.01). On multivariate analysis, gastric distension was an independent predictive factor of infectious pneumonia on Day 5 (Group 3: odds ratio = 16.127 [4.267; 60 959], P < 0.0001). CONCLUSIONS We established, in our cohort of patients, a link between pneumonectomy and gastric distension on Day 1 and infectious pneumonia on Day 5. A prospective multicentre study would be desirable to verify these data.

Objective: This study compares accuracy of sampling versus formal node dissection in patients with primary lung cancer. Patients and methods: During a 4-month period, 208 consecutive patients (172 men, 36 women) without bulky disease underwent resection for primary lung cancer in three centers. The surgeon first sampled the main lymph node stations, and subsequently performed a radical mediastinal dissection. Endpoints were accuracy of prediction for stage N2 and radicality of node sampling compared to dissection. Results: Resection consisted of 1 segmentectomy, 142 standard lobectomies, 6 bilobectomies, 14 sleeve-lobectomies, and 45 pneumonectomies. There were 108 squamous cell carcinomas, 621 adenocarcinomas, 18 bronchoalveolar carcinomas, 8 large cell carcinomas, 4 adenosquamous carcinomas and 8 neuroendocrine carcinomas.Primary tumor was stageT1 in 49patients, T2 in 110,T3 in 43,and T4 in 6. Lymph nodestatus (dissection) was N0in 113, N1in 35, and N2 in 60 patients. N2 disease concerned a single node in 16, a single node station in 19, and multiple levels in 25. Both N1 and N2 nodes were diseased in 36 patients. Samplingadequatelyrecognized N2 diseasein 31patients (52%). Multiple level N2 was accurately identified in 10 patients (40%). Resection based on sampling would have been incomplete in 53 patients (88%). Conclusion: Radical mediastinal dissection is a mandatory adjunct to resection for lung cancer with curative attempt.

In order to provide recommendations regarding implementation of computed tomography (CT) screening in Europe the ESTS established a working group with eight experts in the field. On a background of the current situation regarding CT screening in Europe and the available evidence, ten recommendations have been prepared that cover the essential aspects to be taken into account when considering implementation of CT screening in Europe. These issues are: (i) Implementation of CT screening in Europe, (ii) Participation of thoracic surgeons in CT screening programs, (iii) Training and clinical profile for surgeons participating in screening programs, (iv) the use of minimally invasive thoracic surgery and other relevant surgical issues and (v) Associated elements of CT screening programs (i. e. smoking cessation programs, radiological interpretation, nodule evaluation algorithms and pathology reports). Thoracic Surgeons will play a key role in this process and therefore the ESTS is committed to providing guidance and facilitating this process for the benefit of patients and surgeons.

Objective: This retrospective study evaluates probability of survival and mode of recurrence in patients with a microscopically positive bronchial resection margin following resection for primary bronchogenic carcinoma, as well as influence of radiotherapy on survival. Methods: From January 1986 to July 1997, 40 patients had a microscopically positive bronchial resection margin following a macroscopically complete resection (17 lobectomies, three bilobectomies, four sleeve-lobectomies, and 16 pneumonectomies). Tissue diagnosis was squamous cell carcinoma in 32 patients, adenocarcinoma in four, adenosquamous carcinoma in two and neuroendocrine carcinoma in two. Lymph node status was N0 in 14 patients, N1 in 10, and N2 in 16. The bronchial margin contained carcinoma in situ in 20 patients, invasive mucosal carcinoma in five, and peribronchial infiltration in 15. All patients except the three most recent underwent adjuvant radiation therapy. Results: At the conclusion of the study (January 31st, 1999), 30 patients had died: two with post-operative complications, 17 with progressive disease, ten without relation to cancer, and one under undefined circumstances. Six of 10 unrelated deaths were interpreted as respiratory complications of radiotherapy. Recurrent disease appeared in 24 patients (60%). Nineteen had progression of initial disease (47.5%): metastatic spread in 12 (30%), isolated local recurrence in four (10%), and combined local recurrence and metastases in three (7.5%). Five patients developed metachronous cancer, with bronchial location in four (10%) and laryngeal in one (2.5%). 5-year survival (Kaplan‐Meier) in 20 patients with carcinoma in situ was 38:7 ^ 13:7% (median 31 months), but rose to 55:0 ^ 16:6% when excluding seven deaths not related to cancer (five of whom were secondary to radiotherapy) (x 2 a 3:080; Pa 0:0792). Survival in 13 patients classified N0 was 51:3 ^ 16:3% (median 61 months), and 71:1 ^ 18:0% following exclusion of unrelated deaths (x 2 a 3:939; Pa 0:0472). Adverse prognosis of peribronchial infiltration was correlated to a positive N status (13 N2 and 2 N1), 5-year survival being 20:0 ^ 10:3% (median: 18 months). Conclusions: Prognosis of peribronchial infiltration is similar to N2 disease. In situ carcinoma does not influence survival per se. Local control of disease is probably in part due to radiotherapy. However, the high prevalence of unrelated late deaths suggests an adverse impact of radiotherapy on survival. q 2000 Elsevier Science B.V. All rights reserved.

Training in general thoracic surgery is facing several challenges. There are considerable variations between thoracic surgical training programmes internationally. Some are trained as cardiothoracic surgeons, some monospecialist thoracic surgeons, specialist thoracic and vascular surgeons, while others train as general surgeons with thoracic practice. Training must encompass the evolving treatment strategies, changing guidelines and new technology. Teaching new technology may be challenging when the teacher himself has not been trained for it. There also remains debate around the most effective training methods in a time-pressured environment [1, 2]. Despite the differences, the uniting factor for trainees is often the desire for the best possible training. At the macro-economical level, striving towards a global harmonization of training should facilitate international mobility of specialists. The European Board of Thoracic Surgery offers the possibility for certification by peers, signifying that the individual meets the requirements for independent practice at a high quality level. The European Society of Thoracic Surgeons (ESTS) considers its educational platform as a priority project. In May 2014, the Learning Affairs Committee of the ESTS conducted a trainees’ survey. The purpose for ESTS was to identify topics, which are insufficiently covered by existing training programmes in order to tailor its educational activities. All ESTS trainee members were invited to participate. DEMOGRAPHICS The survey was completed by 48 trainees (18.4% response rate) from 21 countries. The majority were European trainees (n= 43). Others were from Canada (n= 1), India (n= 1), Mexico (n= 1) and the USA (n= 2). Most were training in general thoracic surgery as a monospeciality (n= 24, 50%), 17 (35%) as cardiothoracic surgeons, 6 (13%) as thoracic and general surgeons, 0 as thoracic and vascular surgeons and 1 (2%) was training in another speciality but with thoracic experience. Respondents had primarily been training in thoracic surgery for 65 h. 90% of trainees responded to say they worked more than seven night shifts per month and 65% work more than seven on-call shifts per month. However, 8% of respondents answered to say that they worked >16 on-call shifts every month, and 6% of these were on call for >21 shifts per month. With this in mind, the survey also enquired as to the marital status of trainees. Twenty (42%) were single, 18 (38%) married and 9 (19%) cohabiting. No trainee was divorced.

The purpose of this study was to re-evaluate operative risk and probability for survival patients with a history of upper aerodigestive cancer, who underwent thoracotomy for presumed primary bronchogenic cancer. Our hypothesis was to consider any isolated lung opacity as a primary bronchogenic cancer.The cohort under investigation included 114 consecutive patients. Histology of bronchial cancer was squamous cell carcinoma in 98 patients (86%), adenocarcinoma in 14 (12%) and large cell carcinoma in 2 (2%). Exploratory thoracotomy was performed in 5 patients (4%); the remaining 109 patients underwent a potentially curative resection, including 25 pneumonectomies (22%) and 84 conservative resections (74%). Pathological staging was as follows: 66 stage I (58%), 20 II (17.5%), 20 IIIa (17.5%), 6 stage IIIb (5%), and 2 stage IV (2%).Four patients died post-operatively (3.5%). Non-fatal morbidity concerned 32 patients (28.1%) and was dominated by respiratory superinfections. Incidence of respiratory infections was increased after voice-sparing resections (chi 2 = 4.311, P0.05), and more particularly after transmaxillary buccopharyngectomy (chi 2 = 12.224; P0.01). Estimated 5-year survival was 28.7% (33.3% in stage I, 19.2% in stage II, and 30.2% in stage III). There was no difference in survival with reference to the location of head and neck cancer (chi 2 = 3.412; 0.05P0.1) or chronology (chi 2 = 0.005; P0.9).We conclude that isolated lung opacities in patients with previous or simultaneous head and neck cancer are most likely primary bronchogenic cancers. The acceptable operative mortality legitimizes surgical treatment despite an impaired 5-year survival; patients with a previous voice-sparing operation are at increased risk for respiratory complications and should be managed carefully.

Objective: Epidural analgesia is the gold standard for post-thoracotomy pain relief but is contraindicated in certain patients. An alternative is paravertebral block. We investigated whether ropivacaine, administered through a paravertebral catheter placed by the surgeon, reduced postoperative pain. Methods: In a randomized double-blind study, adult patients with a paravertebral catheter placed by the thoracic surgeon after thoracotomy were randomly assigned to receive through this catheter, either a 0.1 ml kg 1 bolus of 0.5% ropivacaine, followed by a continuous infusion of 0.1 ml kg 1 h 1 for 48 h, or saline at the same scheme of administration. Patients also benefited from patient-controlled analgesia with intravenous morphine (bolus 1 mg, lockout time 7 min), paracetamol, and nefopam. The primary endpoint was pain intensity on a visual analog scale at rest and on coughing. Secondary endpoints were total morphine consumption and side effects during the first 48 postoperative hours. Surgeons, anesthesiologists, and all the nurses and caring staff involved in this study were blinded. Solutions of saline and ropivacaine were prepared identically by the central pharmacy, without any possible identification of the product. Results: Forty-seven patients with contraindications to epidural anesthesia were included. There were no significant differences between the groups receiving ropivacaine and salineintermsofpainseverityatrestandoncoughing,meanpostoperativemorphineconsumption(45.7 mgforropivacaine,43.2 mgincontrols), and incidence of morphine-related side effects (nausea and vomiting, urinary retention, pruritus, respiratory rate, and sedation). Conclusions: Paravertebral block using a catheter placed by the thoracic surgeon was ineffective on postoperative pain after thoracotomy and did not confirm the analgesic effect that has been observed after percutaneous catheter placement. A direct comparison of these two placement methods is required.

Bronchogenic cysts are congenital malformations of the foregut which are generally encountered within the mediastinum. We explored a patient presenting with a cystic, partially calcified tumor in a cervical and retrotracheal location. This lesion was interpreted as a thyroid adenoma preoperatively, but identified as a bronchogenic cyst at pathology.