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Editorial
Cardiothoracic surgery as part of safe executive surgery
Jahangir A. Khan, Ari A. Mennander
Corresponding author
ari.mennander@sydansairaala.fi

Corresponding author.
Tampere University Heart Hospital and Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Cardiothoracic surgery &#8211; an evolving and safe surgical discipline</span><p id="par0005" class="elsevierStylePara elsevierViewall">Traditional cardiac surgery includes full sternotomy and the use of cardiopulmonary bypass&#44; which have been in use for the better part of a century&#46; The safety and success of cardiac surgery have been determined by mastering traditional surgical skills&#46; The cardiac surgeon is recognized as the ultimate leader of the operating team&#44; and the surgeon takes full responsibility of the surgical outcome&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Safety in cardiothoracic surgery requires contemporary knowledge on the efficacy and security of both traditional and modern surgical procedures&#46; Expertise in cardiothoracic surgery mandates not only mastering technical issues during surgery&#44; but also necessitates vast knowledge on available surgical options&#46; Cardiac surgery now encompasses major advances in adapting small incisions&#44; favoring endoscopic approaches and even robotic techniques&#44; which often replace the need of full sternotomy&#46; Transcatheter procedures enable the implantation of new surgical devices percutaneously&#46; Modern hemostatic surgical cutting instruments&#44; tracheal and esophageal stents&#44; intrabronchial valves and plugs&#44; as well as three-dimensional video technology&#44; have expanded the armamentarium of thoracic surgeons&#46; Treatment of thoracic cancer has improved with evolving imaging technologies&#46; Accurate cancer staging obtained by lymph node sampling and dissection add to the efficacy of overall surgical care&#46; Radical resections have become feasible through small incisions&#46; Video-assisted thoracic surgery has enabled early surgery to patients with pleural infections&#44; benign pulmonary&#44; pleural and esophageal diseases&#44; including palliative care&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand&#44; more than 25 years after the first coronary artery bypass grafting without cardiopulmonary bypass&#44; substantial information still support the use of cardiopulmonary bypass to reduce postoperative cardiac events and to secure long-term survival&#46; Despite major advances in the technology of coronary artery intervention&#44; coronary artery bypass grafting offers superior long-term graft patency in patients with complex coronary artery stenosis and left main vessel disease&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Non-medical reasons such as social security&#44; health care system and fashion may influence surgical decision-making&#44; which should not be made at the expense of patient security or based on compromised solution in terms of long-term outcome&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Clearly&#44; future cardiothoracic surgeons require training in catheter-based procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Education on catheter-based procedures expands the expertise of the surgeon to lead the surgical team&#46; To decide for the most adequate&#44; secure and suitable treatment for the individual patient&#44; the future cardiothoracic surgeon needs to master both technical issues of catheter-based procedures and knowledge on the outcome of the specific procedure&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Threats and challenges of safe cardiothoracic surgery</span><p id="par0025" class="elsevierStylePara elsevierViewall">The transcendence of cardiothoracic surgery into the percutaneous world may face several challenges&#44; including local circumstances&#44; financial realities&#44; treatment cultures&#44; and often competing interests among colleagues&#46; Any surgical technique requires a significant amount of experience and repetition for competence&#44; but traditional surgery continues to play a crucial role in patient care as transcatheter procedures may also lead to complications&#46; The ability to treat potential complications aids in controlling percutaneous procedures as well&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The ability to sense tissue and to be perceptible to the sense of touch are delicate features of any surgeon&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Technology has not yet been extended to transferring the sense of touch&#46; Machine learning&#44; wire technology and robotics do not encompass tissue palpation and the sense of soft and hard tissue&#44; and does not differentiate changes in temperature&#46; Decision-making based on quantification&#44; binary digits&#44; flashing lights or warning alarms is regarded as synthetic&#46; The reaction time to complications is prolonged or even disregarded based solely on synthetic alarming&#44; which is often disturbing and unfriendly&#46; The human being is programmed to become numb to repeated irritants&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Lean&#44; efficient&#44; and fast track programs are the present norm&#44; when institutions and individuals compete for numbers&#44; rank&#44; and significance&#44; but efficiency does not guarantee sustainable outcome&#46; The optimal treatment for each patient is the most important facet in practicing medicine&#46; Increasingly sick patients create clear challenges for safe surgery and mastering everything alone may become a waring task in the long run&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Accountability and supportive teamwork enhances safety</span><p id="par0040" class="elsevierStylePara elsevierViewall">The solution is to be able to work together with representatives of cardiology&#44; anesthesiology&#44; radiology&#44; geriatrics&#44; pediatrics&#44; and many other fields&#46; Competitive attention between traditional surgery and transcatheter techniques is no longer a rational endeavor&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Selection of intervention&#44; treatment or diagnostic procedures are only selected upon medical terms&#46; The required treatment path is planned after team discussion and the execution of the surgical plan is directed to a suitable surgical team&#46; Surgical cases are shared collectively among colleagues and distributed according to the competence and experience of the individual surgeon&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> A functioning team secures competence and takes mutual responsibility&#44; and the success of the safe treatment pathway pertains to all members of the team&#46; Each subspecialty maintains their own expertise that is amenable to the individual case&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Surgery in itself is only part of the treatment protocol&#46; Cardiothoracic surgery is being transformed into a new discipline encompassing mastering principles of negotiation in between consultants representing several other subspecialties&#46; Instead of seeking a patient for a definite treatment or intervention that is mastered by a know-it-all specialist&#44; the patient is referred to a group of experts that contemplates different treatment options and selects a treatment pathway suitable to the individual patient&#46; The treatment pathway may include several interventions in a hybrid fashion&#46; Coronary bypass surgery may be performed using partial sternotomy together with percutaneous coronary intervention with cardiopulmonary bypass through the femoral vessels&#46; Transarterial valve replacement and endovascular treatment of the aorta including a local surgical bypass of the head vessels may replace more complex and invasive surgery of the aorta&#46; Depending on the acuity of the disease&#44; such as during aortic dissection and endocarditis&#44; the decision for the individual treatment requires prompt planning and submission to a multi-talent team with active members representing many of the subspecialties ready for an efficient execution of a specific treatment protocol&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">From the patient&#39;s point of view&#44; a seemingly dull and uneventful operation without surprise is often the most secure operation&#46; The aim is to make the surgical procedure fluent while minimizing risks and complications&#46; A straightforward approach using a transfemoral wire technique to implant a cardiac valve may suffice&#44; when a long-term outcome is not aimed for in a frail patient&#46; A patient with intravenous drug abuse may benefit from extended radical surgery due to endocarditis&#46; A pregnant woman with cardiomyopathy and cardiac valve disease may not require immediate surgery and obligatory anticoagulation&#46; A mutual decision with the patient requires maturity&#44; knowledge on surgical techniques&#44; and clinical experience&#46; Mutual accountability supports the responsible surgeon to execute the surgical plan in a secure way&#46; Trustworthy teamwork enhances efficacy and efficiency&#44; and hospital administration may rely on the expertise of the surgical team as a whole to defend the surgical decision-making even legally&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Creating trust and maintaining safe teamwork</span><p id="par0060" class="elsevierStylePara elsevierViewall">The scientific community may help in building trust among peers by adding deeper understanding of our mutual mission to aim for sustainable health care&#46; Being able to participate as a team member requires trust and accountability&#46; Didactic meetings and open discussion with peers in a secure and friendly environment increase the social cohesion of fellow clinicians&#46; Learning from each other is the basis for teamwork&#46; The percutaneous interventions were initiated as an experimental research project&#44; and the prototype for the transcatheter aortic valve replacement device was developed using an experimental animal model&#46; Studies on physiology&#44; pathology&#44; treatment protocols&#44; and practice with devices are feasible as research projects&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Basic&#44; translational and clinical sciences may increase the creative needs to develop safe surgery as a teamwork mission&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="par0065" class="elsevierStylePara elsevierViewall">The surgeon is responsible for the overall surgical process&#44; but the open-minded cardiothoracic surgeon is ready to ponder different treatment options based on traditional and contemporary knowledge to secure safe surgery&#46; Peers and colleagues representing other medical fields may help in the decision-making of the treatment choice for an individual patient&#46; During the execution of the surgical operation&#44; the cardiothoracic surgeon has to trust and keep members of the surgical team accountable for their input in order not to derail from the planned treatment path&#46; Aiming at patient safety during cardiothoracic surgery signifies contemporary knowledge on different surgical options&#44; control of technical challenges and adaptation to supportive teamwork&#46;</p></span></span>"
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Article information
ISSN: 11340096
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos