Working the fundamentals

Ladies and gentlemen, members and guests, It is a great pleasure for me today to stand on this podium in front of you as President of the European Society of Thoracic Surgeons (ESTS), a society which I have had the honour to serve as Councillor, Regent, Editor, local organizer of the annual meeting, and now as President. The Presidential address is perhaps the most hazardous duty of the Presidency because, besides the summary of the recent activities of the Society, I am expected to give you a vision of its future. Unfortunately, I have no crystal ball and my perceptions of the future are very much predicated on my past experiences. ESTS will soon enter its 20th year. The 20th year marks the end of adolescence, a period characterized by striking physiological changes and efforts toward the construction of identity. Adolescence is sometimes viewed as a transitional state, during which young people begin to separate themselves from their parents but still lack a clearly defined role in society. It is generally regarded as an emotionally intense and often stressful period. I joined the ESTS as councillor in those troubled times which culminated—in 2006, after the Stockholm meeting—that marked the end of the Toronto agreement regarding the European Association for Cardio-Thoracic Surgery (EACTS)/ESTS joint meetings. Six years later, ESTS made a success of its transition into independence, as it became the first society in the world dedicated to general thoracic surgery, in terms of membership and attendances at its annual meeting. This required a total re-think of the structure of the Society. The ESTS School has been established and continuously strengthened and its finances have been placed on a very firm footing. It is of course too early for a formal assessment: however, it is crucial for the society's leadership to look ahead to avoid crude errors of management which can lead the most beautiful construction to failure. Undoubtedly, the years ahead will necessitate adaptation to disruptive challenges. It is how we adapt to change which will determine our future. A solid basis for these efforts is to work head-on on those fundamentals that have made us successful. More than ten years ago, Heikki Toomes concluded his ESTS Presidential address with the statement that there was a strong need for a monospeciality for General Thoracic Surgery in Europe [1]. The trend was initiated worldwide in the 1980s, when general thoracic surgery had been pushed into a minor role as a result of the enormous expansion of heart surgery. Nowadays, this is not the case. Very few surgical specialties offer such a wide field of different activities as general thoracic surgery proposes with oncology, infectious diseases, transplantation, trauma, cosmetic and functional surgeries of the chest. This spectrum is actually now so large that very few departments can embrace it fully. Because of high proportions of cancer patients—about 70%—thoracic surgery in Europe today is, for the most part, oncological surgery. Most thoracic malignancies—lung cancer in particular—still show an increased incidence, especially in eastern European countries. In 2012, lung cancer will kill three times more people in Europe than any other cancer. Its high fatality rate highlights continuing severe limitations of therapy. Most lung carcinomas are still diagnosed at an advanced stage, conferring a poor prognosis. Indeed, the 5-year survival rate within Europe still is around 10%. The need to diagnose lung cancer at an earlier—and potentially curable—stage has recently been supported by the initial results of the National Lung Screening Trial, which show 20% fewer lung cancer deaths among current or former heavy smokers screened by low-dose helical CT, compared with those screened by chest X-ray. Such innovation, however, raises many questions and represents, in a globalized world, a great opportunity for lung cancer clinicians to work together to integrate and refine this new approach within future clinical trials and national screening programs [2]. The ESTS could not remain outside such a process. Accordingly, a think tank has been set up under the umbrella of the International Association for the Study of Lung Cancer (IASLC)—which includes ESTS representatives. The development in Europe of screening programs would probably increase the number of patients the thoracic surgeon will have to deal with during at least the next two decades. Part of the future of surgical techniques will be driven by this development, with a likelihood that more early-stage cancers will present and may be amenable to minimally invasive surgical approaches, with the possibility of a role for robotics. However, new evidence should be recognized. After decades of nihilism, effective alternative treatment options now exist. Stereotactic radiotherapy and radiofrequency, as alternatives to lung cancer surgery, yield substantial cure rates in patients with early stage disease. Their associated risk–benefit ratios compare favourably with open surgery in elderly patients, patients with severe lung and/or heart diseases and patients with multiple co-morbidities. It is very likely that these techniques will be very quickly applied to the standard patients and may be at the request of the patients themselves, even in the absence of—or even in contradiction of—solid long-term data. This scenario gives us an impression of ‘déjà vu’ with what cardiac surgeons had to face with coronary artery angioplasty and stenting and, more recently, percutaneous heart valve implantation. On the other edge of the spectrum is surgery for advanced-stage disease. Evidence-based medicine suggests that the long-term survival of patients who have received extended and complex surgery in this setting is poor—and probably worse than that of patients treated by concomitant chemo-radiotherapy alone. In turn, most currently available treatment guidelines narrow the role of surgery in advanced stage disease, and support selective referral to expert centres. This term, ‘expert centres’, is definitely not well-defined. Currently used surrogates, such as the volume of activity, the academic or non-academic setting, and the exclusive or non-exclusive dedication of the institution to cancer diseases may not be compatible with every national health system. The ESTS must make its voice heard on this issue. A dedicated labelling process should be set up, similar to the one used for certification. Meanwhile, lung cancer patients have seen tremendous changes in their management. Improvements in perioperative therapies demand flawless mediastinal staging, and sometimes restaging with a combination of endoscopic and invasive procedures. Moreover, advances in molecular biology require that surgeons supply samples of tumour and lymph node tissue to fully characterize the disease, as it is likely that the genetic fingerprint of the disease will provide a biological ultrastaging to hopefully supersede anatomical staging soon. Indeed, biomarkers to drive therapeutic choices are beginning to impact patient care. Although modern algorithms for individualized, targeted therapy in NSCLC are basically based on studies from metastatic stage disease, adjuvant treatment for earlier stages is progressing rapidly. As surgeons, we will have to remain well-informed and be active participants in integrated, multimodal approaches to lung cancer management. Gaetano Rocco—to whom our society is indebted for having such strategizing and visionary contributions—understood early that surgeons must remain engaged in this aspect of science or else risk relegation to the sidelines in treating these patients [3]. He thus came up with the idea of the ‘Biology Club’, after having created the ad hoc committee for regenerative therapies. The first public meeting of the Biology Club was held in Marseille at the 19th ESTS conference and was a great success, especially among our youngest members—the future of our society. Unfortunately, for logistical reasons, it was impossible to set up a second session this year. I am convinced that it is a mistake that we shall correct in the coming years because surgeons are—and should remain—central partners in translational research. The oesophagus bears witness to the dual origin of modern thoracic surgery which, in many countries, originates from general surgery as a separate branch from the one which also gave birth to cardiac surgery. However, contrary to other parts of the world—and especially the USA—oesophageal surgery in Europe is now mainly performed by GI surgeons. This trend is somewhat paradoxical, since most postoperative complications involve the mediastinum, the pleural spaces and the lungs. Such a statement is all the most obvious that, as a mirror effect, oesophageal surgery is performed by a small number of GI teams that constitute a confidential club of initiated surgeons with narrow stands and poorly ranked journals as a consequence of a limited and scattered readership. In contrast, those thoracic surgeons who are involved in oesophageal surgery usually have a high volume of activity, a special interest in research and a leading position in scientific arenas. This statement is typically illustrated by the surgical careers of two ESTS past presidents, Antoon Lerut and my own mentor, Pierre Fuentes. Oesophageal surgery is undoubtedly not for the occasional surgeon. However, every thoracic surgeon has almost routinely to face thoracic problems originating from the oesophagus. This fact (and facts are stubborn) focuses the need to convincingly keep the oesophagus inside the spectrum of thoracic surgery, at least in terms of training and continuous education. The ESTS must continue to play a leading role in this field, even if collaborative multidisciplinary efforts should support its action. Organ transplantation has been one of the major medical achievements of the twenty-first century. The lungs proved to be one of the most difficult organs to transplant, thus explaining why lung transplantation is still considered to be in its youth. Anyway, the results have steadily improved and the procedure is now accepted as the standard treatment for patients with end-stage parenchymal and vascular lung diseases. However, in Europe this activity remains limited to countries with the highest incomes and, in those countries, to a small number of institutions. I had the chance to begin my residency in surgery at the time when the first bilateral lung transplantation in France was performed in Marseille and I am now leading one of the most active programs in my country. One of the most striking inputs of the last decade in this setting is undoubtedly ECMO (extracorporeal membrane oxygen) technology. Tremendous progress has been made in terms of miniaturization, ergonomics, simplicity of use with percutaneous cannulations and pre-heparinized disposable circuits. In a short period of time, ECMO has replaced conventional cardiopulmonary by-pass whenever extracorporeal haemodynamic or oxygenation support is required. It is also now used routinely as a bridge to transplantation when the condition of patients on the waiting list worsens. In this setting, it may be used in awake, autonomously breathing patients. ECMO especially changed the care of recipients with severe primary graft dysfunction by reducing by 3 the related mortality. Most importantly, ECMO has spread outside the narrow and ultraspecialized field of lung transplantation to become the mainstay of the treatment of severe ARDS patients. Besides its use as a life-saving procedure in the acute setting, ECMO is also a safe alternative to ventilation through the operative field in complex laryngotracheal and/or carinal scheduled surgeries. These variations of its novel applications have been tested and used over the very last few years and are still expanding, making it an important tool in the armamentarium of general thoracic surgeons. This is not without significant consequences for the future of our specialty. In my humble opinion, it gets away from any vague desire of schism between general thoracic surgery and cardiovascular surgery. Common training and collaboration in practice and in science still remain essential. However we, as a society devoted to general thoracic surgery, must set up dedicated educational courses to help our members and trainees to embrace and to feel comfortable with this technology. An ESTS ECMO school is thus desirable, as are the efforts the ESTS leadership should make with the industry so that it understands that we have become major partners in this field. Since 1999, the European Journal of Cardio-Thoracic Surgery (EJCTS) has been the official organ of our society. Being also that of the EACTS, it demonstrates that an excellent partnership is possible and desirable between both societies and between thoracic and cardiac surgeons for the sake of our specialty. Its current ranking in the international bibliometric systems makes it very well established as one of the three major thoracic journals. I enjoyed the job of ESTS Editor very much during three hard-working years. I would like to take this opportunity to acknowledge the tremendous work done by our current Editor, Gonzalo Varela. As often discussed within Council, there can be many good reasons for starting a new scientific journal. To be attractive to authors, however, this journal should be indexed and get an impact factor quickly, since the latter is used to evaluate the individual researcher. This goal may lead to adoption of editorial policies—not necessarily with sinister intent—that increase its impact factor but that can be detrimental for the author- and readerships. For instance, the journal may choose to publish a larger percentage of review articles which generally are cited more than original research reports, to the detriment of these latter. In the meantime, it may also choose not to publish minor articles, such as case reports, which are unlikely to be cited but which often represent the first attempt at publication, especially for young authors and members. On the other hand, in the long run, editorial policies that are not IF-driven carry the risk to place the journal , and the society that it represents, in a position of lesser importance. It is my strong belief that we never have to make a commitment in this way, particularly as the scientific visibility of our society has never been so high. We have to mobilize all our energy to strengthen the position of the ESTS inside the Journal, to improve the visibility and the quality of thoracic papers, and to reserve the best of our production for the EJCTS. The Council also recognized a real need for the publication of material which was not necessarily within the scope of a purely scientific journal. 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This initiated by our is also expected to improve our visibility among industry health and patients For this is a major for the years we will have to with no alternative but To to face changes we must work on We must our we must be with we must embrace new we must our scientific we must of to the to thoracic we must continue to structure and we must our journal and our we must adapt our to our we must strengthen our It is definitely the end of the beginning of ESTS I could not this address without my to three my who gave me such for continuous support and my surgical without whom I would not have been to the that I have the honour to lead and the and of the ESTS for at least the last for his and It was an a and a pleasure to serve as President.

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