Thoracic Surgery News (Archived)

The first-ever AATS Mitral Conclave was held on May 5^th and 6^th. The world’s leading experts in mitral valve disease convened to discuss management guidelines, imaging, pathology, minimally invasive procedures, percutaneous approaches, surgical techniques, devices, and long-term results.

"With 39 faculty and 250 presentations, including selected abstracts and videos, our goal was to have a comprehensive meeting focused on mitral valve disease that would allow attendees to gain exposure to all of the common approaches used in the top centers throughout the world," said Program Director David H. Adams, MD. "We continue to see tremendous progress in our understanding of mitral disease intervention, and a great interest among surgeons in learning and advancing mitral valve repair strategies," said Dr. Adams, chairman of the department of cardiothoracic surgery at the Mount Sinai Medical Center, New York.

More than 1,000 individuals – including about 800 physicians – from 66 countries participated. Industry support was provided by Edwards Lifesciences LLC (Premier Platinum), Metronic, Inc. (Platinum), Abbott Vascular (Gold), Sorin Heart Valves (Gold), and St. Jude Medical Inc. (Bronze).

"I figured we might get 250 physicians, and would have considered that a success. This is fantastic," said AATS President Irving L. Kron, MD.

Presentations included lectures, expert video sessions, and "Presentations on Demand," accessible on video screens positioned in the exhibit hall. In a plenary address, Robert O. Bonow, MD, said that current valvular heart disease guidelines are based largely on expert opinion rather than evidence from clinical trials. Referring to the 2008 revised joint guidelines from the American College of Cardiology/American Heart Association and the 2007 European Society of Cardiology guidelines, he said, "Unfortunately, the evidence base underpinning them is limited by an inadequate number of randomized clinical trials. We really need to provide more evidence-based information to devise true guidelines and performance measures."

The question of whether mitral valve repair should be considered in all patients with severe mitral valve regurgitation is still being debated.

"It’s at least likely that certain patient subsets would benefit, but current data are insufficient to determine which ones," said Dr. Bonow, of Northwestern University. As an example of ambiguity, U.S. guidelines recommend that patients considered eligible for repair be referred to an "experienced center," but don’t provide criteria for determining that status. Moreover, individual surgeon volume and experience clearly predict successful mitral repair outcomes, even within one institution.

Dr. Bonow is optimistic that useful data will come from two ongoing trials sponsored by the National Heart, Lung, and Blood Institute via the Cardiothoracic Surgical Trials Network.

Dr. Adams presented the Mitral Conclave Career Achievement Award to the legendary Alain F. Carpentier, MD, whose 1983 landmark paper, "Cardiac Valve Surgery – the ‘French Correction,’ " is credited with heralding the modern era of mitral valve reconstructive surgery. Professor Carpentier delivered the Conclave Honored Lecture.

A series of "mini debates" addressed controversies surrounding the use of annuloplasty rings (flexible versus remodeling versus no ring at all), minimally invasive surgery (for all patients versus for some), and the correct approach for specific clinical scenarios of tricuspid valve disease.

The next Aortic Symposium will be held April 26-27, 2012, and the next Mitral Conclave will take place May 2-3, 2013, both in New York. Proceedings from the 2011 Mitral Conclave will be published in an upcoming supplement to The Journal of Thoracic and Cardiovascular Surgery.n

The first-ever AATS Mitral Conclave was held on May 5^th and 6^th. The world’s leading experts in mitral valve disease convened to discuss management guidelines, imaging, pathology, minimally invasive procedures, percutaneous approaches, surgical techniques, devices, and long-term results.

"With 39 faculty and 250 presentations, including selected abstracts and videos, our goal was to have a comprehensive meeting focused on mitral valve disease that would allow attendees to gain exposure to all of the common approaches used in the top centers throughout the world," said Program Director David H. Adams, MD. "We continue to see tremendous progress in our understanding of mitral disease intervention, and a great interest among surgeons in learning and advancing mitral valve repair strategies," said Dr. Adams, chairman of the department of cardiothoracic surgery at the Mount Sinai Medical Center, New York.

More than 1,000 individuals – including about 800 physicians – from 66 countries participated. Industry support was provided by Edwards Lifesciences LLC (Premier Platinum), Metronic, Inc. (Platinum), Abbott Vascular (Gold), Sorin Heart Valves (Gold), and St. Jude Medical Inc. (Bronze).

"I figured we might get 250 physicians, and would have considered that a success. This is fantastic," said AATS President Irving L. Kron, MD.

Presentations included lectures, expert video sessions, and "Presentations on Demand," accessible on video screens positioned in the exhibit hall. In a plenary address, Robert O. Bonow, MD, said that current valvular heart disease guidelines are based largely on expert opinion rather than evidence from clinical trials. Referring to the 2008 revised joint guidelines from the American College of Cardiology/American Heart Association and the 2007 European Society of Cardiology guidelines, he said, "Unfortunately, the evidence base underpinning them is limited by an inadequate number of randomized clinical trials. We really need to provide more evidence-based information to devise true guidelines and performance measures."

The question of whether mitral valve repair should be considered in all patients with severe mitral valve regurgitation is still being debated.

"It’s at least likely that certain patient subsets would benefit, but current data are insufficient to determine which ones," said Dr. Bonow, of Northwestern University. As an example of ambiguity, U.S. guidelines recommend that patients considered eligible for repair be referred to an "experienced center," but don’t provide criteria for determining that status. Moreover, individual surgeon volume and experience clearly predict successful mitral repair outcomes, even within one institution.

Dr. Bonow is optimistic that useful data will come from two ongoing trials sponsored by the National Heart, Lung, and Blood Institute via the Cardiothoracic Surgical Trials Network.

Dr. Adams presented the Mitral Conclave Career Achievement Award to the legendary Alain F. Carpentier, MD, whose 1983 landmark paper, "Cardiac Valve Surgery – the ‘French Correction,’ " is credited with heralding the modern era of mitral valve reconstructive surgery. Professor Carpentier delivered the Conclave Honored Lecture.

A series of "mini debates" addressed controversies surrounding the use of annuloplasty rings (flexible versus remodeling versus no ring at all), minimally invasive surgery (for all patients versus for some), and the correct approach for specific clinical scenarios of tricuspid valve disease.

The next Aortic Symposium will be held April 26-27, 2012, and the next Mitral Conclave will take place May 2-3, 2013, both in New York. Proceedings from the 2011 Mitral Conclave will be published in an upcoming supplement to The Journal of Thoracic and Cardiovascular Surgery.n

The first-ever AATS Mitral Conclave was held on May 5^th and 6^th. The world’s leading experts in mitral valve disease convened to discuss management guidelines, imaging, pathology, minimally invasive procedures, percutaneous approaches, surgical techniques, devices, and long-term results.

"With 39 faculty and 250 presentations, including selected abstracts and videos, our goal was to have a comprehensive meeting focused on mitral valve disease that would allow attendees to gain exposure to all of the common approaches used in the top centers throughout the world," said Program Director David H. Adams, MD. "We continue to see tremendous progress in our understanding of mitral disease intervention, and a great interest among surgeons in learning and advancing mitral valve repair strategies," said Dr. Adams, chairman of the department of cardiothoracic surgery at the Mount Sinai Medical Center, New York.

More than 1,000 individuals – including about 800 physicians – from 66 countries participated. Industry support was provided by Edwards Lifesciences LLC (Premier Platinum), Metronic, Inc. (Platinum), Abbott Vascular (Gold), Sorin Heart Valves (Gold), and St. Jude Medical Inc. (Bronze).

"I figured we might get 250 physicians, and would have considered that a success. This is fantastic," said AATS President Irving L. Kron, MD.

Presentations included lectures, expert video sessions, and "Presentations on Demand," accessible on video screens positioned in the exhibit hall. In a plenary address, Robert O. Bonow, MD, said that current valvular heart disease guidelines are based largely on expert opinion rather than evidence from clinical trials. Referring to the 2008 revised joint guidelines from the American College of Cardiology/American Heart Association and the 2007 European Society of Cardiology guidelines, he said, "Unfortunately, the evidence base underpinning them is limited by an inadequate number of randomized clinical trials. We really need to provide more evidence-based information to devise true guidelines and performance measures."

The question of whether mitral valve repair should be considered in all patients with severe mitral valve regurgitation is still being debated.

"It’s at least likely that certain patient subsets would benefit, but current data are insufficient to determine which ones," said Dr. Bonow, of Northwestern University. As an example of ambiguity, U.S. guidelines recommend that patients considered eligible for repair be referred to an "experienced center," but don’t provide criteria for determining that status. Moreover, individual surgeon volume and experience clearly predict successful mitral repair outcomes, even within one institution.

Dr. Bonow is optimistic that useful data will come from two ongoing trials sponsored by the National Heart, Lung, and Blood Institute via the Cardiothoracic Surgical Trials Network.

Dr. Adams presented the Mitral Conclave Career Achievement Award to the legendary Alain F. Carpentier, MD, whose 1983 landmark paper, "Cardiac Valve Surgery – the ‘French Correction,’ " is credited with heralding the modern era of mitral valve reconstructive surgery. Professor Carpentier delivered the Conclave Honored Lecture.

A series of "mini debates" addressed controversies surrounding the use of annuloplasty rings (flexible versus remodeling versus no ring at all), minimally invasive surgery (for all patients versus for some), and the correct approach for specific clinical scenarios of tricuspid valve disease.

The next Aortic Symposium will be held April 26-27, 2012, and the next Mitral Conclave will take place May 2-3, 2013, both in New York. Proceedings from the 2011 Mitral Conclave will be published in an upcoming supplement to The Journal of Thoracic and Cardiovascular Surgery.n

The Cardiothoracic Surgery Research Program is an intramural research program within the National Heart, Lung, and Blood Institute at the NIH in Bethesda Md. The Director of the laboratory is Dr. Keith A. Horvath,

Currently the program focuses on three major research areas, represented by sections: cell-based therapy, bioengineering, and transplantation. In their 2010 quadrennial report, the group detailed 4 years of significant translational research"representing the return of cardiothoracic research to the NHLBI after a hiatus since 1990," according to Dr. Horvath.

The Cellular Biology Section is focused on cell-based therapy for myocardial ischemia using adult bone-marrow-derived mesenchymal stem cells (BMSCs).

Their research aims are focused on a large animal model to test the effects of BMSCs on chronic myocardial ischemia, to study the fate and differentiation of BMSCs after administration, and to further investigate gene expression patterns of BMSCs under both normoxic and hypoxic conditions.

The group has already demonstrated the benefits of direct injection of autologous BMSCs in to chronically ischemic myocardium.

Direct injection of autologous BMSCs into the ischemic myocardium showed regional ventricular wall thickening demonstrating significant improvement after cell treatment, whereas saline treated animals showed no improvement compared to baseline as assessed by echocardiography.

Global function was also improved following BMSC injection and increased vascularity was found in the BMSC group compared to saline injected controls.

BMSCs isolated from transgenic pigs designed to express enhanced green fluorescent proteins as the donors showed that allogeneic injection of the green BMSCs is safe, with no observable side effects or signs of graft versus host disease were observed.

The green cells were found migrating from the injected area into deeper layers of myocardium over the course of 1 to 6 weeks. By immunofluorescent staining, the green cells were associated with smooth muscle actin or vWF positive cells, suggesting that the transplanted cells were contributing to the formation of new vessels.

They found no evidence that these cells were associated with the new generation of cardiac myocytes, which suggests that the benefits of this therapy may be due to angiogenesis not the regeneration of cardiac myocytes. Gene profiling of the cells before and after transplantation showed that genes such as VEGF, HIF1-a, PDGF, ANGPT2 and CXCL14 were significantly up-regulated.

A clinical trial will be conducted at the NIH Heart Center at Suburban Hospital, Bethesda, and will follow the direct injection of BSMCs into ischemic areas in patients after coronary artery bypass grafting (CABG) or transmyocardial revascularization.

The Transplantation Section at CSRP has focused on developing a clinically relevant large animal cardiac xenotransplantation model, using genetically engineered pig hearts place in baboons.

Efforts are being focused on appropriate immunosuppression through drugs, stem cell, and genetic-engineering of donor hearts. These research efforts involve a working collaboration with Mayo Clinic, University of Pittsburgh, University of Maryland, Beth Israel Hospital, NIH Swine Center in Missouri, and Revivicor.

The Bioengineering Section is focused on developing and applying engineering technologies with devices, imaging and robotics with the goal of achieving "state-of-the-art minimally invasive cardiac operations.

"By enhancing precision and consistency, these novel procedures will improve clinical outcomes and expand the cohort of patients that can be treated."

The current work focuses on beating heart aortic valve replacement under real-time MRI guidance. Feasibility studies have been completed and long term animal studies are underway.

Active and passive markers have been added to the prostheses and delivery device to aid visualization and allow placement of the valve with the precision achieved in an open surgical procedure in 1/100th the time. The current goal is to translate this work into a clinical trial.

This column will keep track of these and other research efforts conducted by the CSRP, especially as they move from preclinical to clinical applications of their advanced research.☐

The Cardiothoracic Surgery Research Program is an intramural research program within the National Heart, Lung, and Blood Institute at the NIH in Bethesda Md. The Director of the laboratory is Dr. Keith A. Horvath,

Currently the program focuses on three major research areas, represented by sections: cell-based therapy, bioengineering, and transplantation. In their 2010 quadrennial report, the group detailed 4 years of significant translational research"representing the return of cardiothoracic research to the NHLBI after a hiatus since 1990," according to Dr. Horvath.

The Cellular Biology Section is focused on cell-based therapy for myocardial ischemia using adult bone-marrow-derived mesenchymal stem cells (BMSCs).

Their research aims are focused on a large animal model to test the effects of BMSCs on chronic myocardial ischemia, to study the fate and differentiation of BMSCs after administration, and to further investigate gene expression patterns of BMSCs under both normoxic and hypoxic conditions.

The group has already demonstrated the benefits of direct injection of autologous BMSCs in to chronically ischemic myocardium.

Direct injection of autologous BMSCs into the ischemic myocardium showed regional ventricular wall thickening demonstrating significant improvement after cell treatment, whereas saline treated animals showed no improvement compared to baseline as assessed by echocardiography.

Global function was also improved following BMSC injection and increased vascularity was found in the BMSC group compared to saline injected controls.

BMSCs isolated from transgenic pigs designed to express enhanced green fluorescent proteins as the donors showed that allogeneic injection of the green BMSCs is safe, with no observable side effects or signs of graft versus host disease were observed.

The green cells were found migrating from the injected area into deeper layers of myocardium over the course of 1 to 6 weeks. By immunofluorescent staining, the green cells were associated with smooth muscle actin or vWF positive cells, suggesting that the transplanted cells were contributing to the formation of new vessels.

They found no evidence that these cells were associated with the new generation of cardiac myocytes, which suggests that the benefits of this therapy may be due to angiogenesis not the regeneration of cardiac myocytes. Gene profiling of the cells before and after transplantation showed that genes such as VEGF, HIF1-a, PDGF, ANGPT2 and CXCL14 were significantly up-regulated.

A clinical trial will be conducted at the NIH Heart Center at Suburban Hospital, Bethesda, and will follow the direct injection of BSMCs into ischemic areas in patients after coronary artery bypass grafting (CABG) or transmyocardial revascularization.

The Transplantation Section at CSRP has focused on developing a clinically relevant large animal cardiac xenotransplantation model, using genetically engineered pig hearts place in baboons.

Efforts are being focused on appropriate immunosuppression through drugs, stem cell, and genetic-engineering of donor hearts. These research efforts involve a working collaboration with Mayo Clinic, University of Pittsburgh, University of Maryland, Beth Israel Hospital, NIH Swine Center in Missouri, and Revivicor.

The Bioengineering Section is focused on developing and applying engineering technologies with devices, imaging and robotics with the goal of achieving "state-of-the-art minimally invasive cardiac operations.

"By enhancing precision and consistency, these novel procedures will improve clinical outcomes and expand the cohort of patients that can be treated."

The current work focuses on beating heart aortic valve replacement under real-time MRI guidance. Feasibility studies have been completed and long term animal studies are underway.

Active and passive markers have been added to the prostheses and delivery device to aid visualization and allow placement of the valve with the precision achieved in an open surgical procedure in 1/100th the time. The current goal is to translate this work into a clinical trial.

This column will keep track of these and other research efforts conducted by the CSRP, especially as they move from preclinical to clinical applications of their advanced research.☐

The Cardiothoracic Surgery Research Program is an intramural research program within the National Heart, Lung, and Blood Institute at the NIH in Bethesda Md. The Director of the laboratory is Dr. Keith A. Horvath,

Currently the program focuses on three major research areas, represented by sections: cell-based therapy, bioengineering, and transplantation. In their 2010 quadrennial report, the group detailed 4 years of significant translational research"representing the return of cardiothoracic research to the NHLBI after a hiatus since 1990," according to Dr. Horvath.

The Cellular Biology Section is focused on cell-based therapy for myocardial ischemia using adult bone-marrow-derived mesenchymal stem cells (BMSCs).

Their research aims are focused on a large animal model to test the effects of BMSCs on chronic myocardial ischemia, to study the fate and differentiation of BMSCs after administration, and to further investigate gene expression patterns of BMSCs under both normoxic and hypoxic conditions.

The group has already demonstrated the benefits of direct injection of autologous BMSCs in to chronically ischemic myocardium.

Direct injection of autologous BMSCs into the ischemic myocardium showed regional ventricular wall thickening demonstrating significant improvement after cell treatment, whereas saline treated animals showed no improvement compared to baseline as assessed by echocardiography.

Global function was also improved following BMSC injection and increased vascularity was found in the BMSC group compared to saline injected controls.

BMSCs isolated from transgenic pigs designed to express enhanced green fluorescent proteins as the donors showed that allogeneic injection of the green BMSCs is safe, with no observable side effects or signs of graft versus host disease were observed.

The green cells were found migrating from the injected area into deeper layers of myocardium over the course of 1 to 6 weeks. By immunofluorescent staining, the green cells were associated with smooth muscle actin or vWF positive cells, suggesting that the transplanted cells were contributing to the formation of new vessels.

They found no evidence that these cells were associated with the new generation of cardiac myocytes, which suggests that the benefits of this therapy may be due to angiogenesis not the regeneration of cardiac myocytes. Gene profiling of the cells before and after transplantation showed that genes such as VEGF, HIF1-a, PDGF, ANGPT2 and CXCL14 were significantly up-regulated.

A clinical trial will be conducted at the NIH Heart Center at Suburban Hospital, Bethesda, and will follow the direct injection of BSMCs into ischemic areas in patients after coronary artery bypass grafting (CABG) or transmyocardial revascularization.

The Transplantation Section at CSRP has focused on developing a clinically relevant large animal cardiac xenotransplantation model, using genetically engineered pig hearts place in baboons.

Efforts are being focused on appropriate immunosuppression through drugs, stem cell, and genetic-engineering of donor hearts. These research efforts involve a working collaboration with Mayo Clinic, University of Pittsburgh, University of Maryland, Beth Israel Hospital, NIH Swine Center in Missouri, and Revivicor.

The Bioengineering Section is focused on developing and applying engineering technologies with devices, imaging and robotics with the goal of achieving "state-of-the-art minimally invasive cardiac operations.

"By enhancing precision and consistency, these novel procedures will improve clinical outcomes and expand the cohort of patients that can be treated."

The current work focuses on beating heart aortic valve replacement under real-time MRI guidance. Feasibility studies have been completed and long term animal studies are underway.

Active and passive markers have been added to the prostheses and delivery device to aid visualization and allow placement of the valve with the precision achieved in an open surgical procedure in 1/100th the time. The current goal is to translate this work into a clinical trial.

This column will keep track of these and other research efforts conducted by the CSRP, especially as they move from preclinical to clinical applications of their advanced research.☐

AATS Resident Resources:

www.aats.org/TSR/index.html

CTSNET Residents Section:

www.ctsnet.org/sections/residents

Thoracic Surgery Directors Association:

www.tsda.org

Thoracic Surgery Foundation for Research and Education:

www.tsfre.org

Thoracic Surgery News:

www.thoracicsurgerynews.com

Thoracic Surgery Residents Association:

www.tsranet.org

AATS Resident Resources:

www.aats.org/TSR/index.html

CTSNET Residents Section:

www.ctsnet.org/sections/residents

Thoracic Surgery Directors Association:

www.tsda.org

Thoracic Surgery Foundation for Research and Education:

www.tsfre.org

Thoracic Surgery News:

www.thoracicsurgerynews.com

Thoracic Surgery Residents Association:

www.tsranet.org

AATS Resident Resources:

www.aats.org/TSR/index.html

CTSNET Residents Section:

www.ctsnet.org/sections/residents

Thoracic Surgery Directors Association:

www.tsda.org

Thoracic Surgery Foundation for Research and Education:

www.tsfre.org

Thoracic Surgery News:

www.thoracicsurgerynews.com

Thoracic Surgery Residents Association:

www.tsranet.org

The first-ever AATS Mitral Conclave was held on May 5^th and 6^th. The world’s leading experts in mitral valve disease convened to discuss management guidelines, imaging, pathology, minimally invasive procedures, percutaneous approaches, surgical techniques, devices, and long-term results.

"With 39 faculty and 250 presentations, including selected abstracts and videos, our goal was to have a comprehensive meeting focused on mitral valve disease that would allow attendees to gain exposure to all of the common approaches used in the top centers throughout the world," said Program Director David H. Adams, MD. "We continue to see tremendous progress in our understanding of mitral disease intervention, and a great interest among surgeons in learning and advancing mitral valve repair strategies," said Dr. Adams, chairman of the department of cardiothoracic surgery at the Mount Sinai Medical Center, New York.

More than 1,000 individuals – including about 800 physicians – from 66 countries participated. Industry support was provided by Edwards Lifesciences LLC (Premier Platinum), Metronic, Inc. (Platinum), Abbott Vascular (Gold), Sorin Heart Valves (Gold), and St. Jude Medical Inc. (Bronze).

"I figured we might get 250 physicians, and would have considered that a success. This is fantastic," said AATS President Irving L. Kron, MD.

Presentations included lectures, expert video sessions, and "Presentations on Demand," accessible on video screens positioned in the exhibit hall. In a plenary address, Robert O. Bonow, MD, said that current valvular heart disease guidelines are based largely on expert opinion rather than evidence from clinical trials. Referring to the 2008 revised joint guidelines from the American College of Cardiology/American Heart Association and the 2007 European Society of Cardiology guidelines, he said, "Unfortunately, the evidence base underpinning them is limited by an inadequate number of randomized clinical trials. We really need to provide more evidence-based information to devise true guidelines and performance measures."

The question of whether mitral valve repair should be considered in all patients with severe mitral valve regurgitation is still being debated.

"It’s at least likely that certain patient subsets would benefit, but current data are insufficient to determine which ones," said Dr. Bonow, of Northwestern University. As an example of ambiguity, U.S. guidelines recommend that patients considered eligible for repair be referred to an "experienced center," but don’t provide criteria for determining that status. Moreover, individual surgeon volume and experience clearly predict successful mitral repair outcomes, even within one institution.

Dr. Bonow is optimistic that useful data will come from two ongoing trials sponsored by the National Heart, Lung, and Blood Institute via the Cardiothoracic Surgical Trials Network.

Dr. Adams presented the Mitral Conclave Career Achievement Award to the legendary Alain F. Carpentier, MD, whose 1983 landmark paper, "Cardiac Valve Surgery – the ‘French Correction,’ " is credited with heralding the modern era of mitral valve reconstructive surgery. Professor Carpentier delivered the Conclave Honored Lecture.

A series of "mini debates" addressed controversies surrounding the use of annuloplasty rings (flexible versus remodeling versus no ring at all), minimally invasive surgery (for all patients versus for some), and the correct approach for specific clinical scenarios of tricuspid valve disease.

The next Aortic Symposium will be held April 26-27, 2012, and the next Mitral Conclave will take place May 2-3, 2013, both in New York. Proceedings from the 2011 Mitral Conclave will be published in an upcoming supplement to The Journal of Thoracic and Cardiovascular Surgery.n

The first-ever AATS Mitral Conclave was held on May 5^th and 6^th. The world’s leading experts in mitral valve disease convened to discuss management guidelines, imaging, pathology, minimally invasive procedures, percutaneous approaches, surgical techniques, devices, and long-term results.

"With 39 faculty and 250 presentations, including selected abstracts and videos, our goal was to have a comprehensive meeting focused on mitral valve disease that would allow attendees to gain exposure to all of the common approaches used in the top centers throughout the world," said Program Director David H. Adams, MD. "We continue to see tremendous progress in our understanding of mitral disease intervention, and a great interest among surgeons in learning and advancing mitral valve repair strategies," said Dr. Adams, chairman of the department of cardiothoracic surgery at the Mount Sinai Medical Center, New York.

More than 1,000 individuals – including about 800 physicians – from 66 countries participated. Industry support was provided by Edwards Lifesciences LLC (Premier Platinum), Metronic, Inc. (Platinum), Abbott Vascular (Gold), Sorin Heart Valves (Gold), and St. Jude Medical Inc. (Bronze).

"I figured we might get 250 physicians, and would have considered that a success. This is fantastic," said AATS President Irving L. Kron, MD.

Presentations included lectures, expert video sessions, and "Presentations on Demand," accessible on video screens positioned in the exhibit hall. In a plenary address, Robert O. Bonow, MD, said that current valvular heart disease guidelines are based largely on expert opinion rather than evidence from clinical trials. Referring to the 2008 revised joint guidelines from the American College of Cardiology/American Heart Association and the 2007 European Society of Cardiology guidelines, he said, "Unfortunately, the evidence base underpinning them is limited by an inadequate number of randomized clinical trials. We really need to provide more evidence-based information to devise true guidelines and performance measures."

The question of whether mitral valve repair should be considered in all patients with severe mitral valve regurgitation is still being debated.

"It’s at least likely that certain patient subsets would benefit, but current data are insufficient to determine which ones," said Dr. Bonow, of Northwestern University. As an example of ambiguity, U.S. guidelines recommend that patients considered eligible for repair be referred to an "experienced center," but don’t provide criteria for determining that status. Moreover, individual surgeon volume and experience clearly predict successful mitral repair outcomes, even within one institution.

Dr. Bonow is optimistic that useful data will come from two ongoing trials sponsored by the National Heart, Lung, and Blood Institute via the Cardiothoracic Surgical Trials Network.

Dr. Adams presented the Mitral Conclave Career Achievement Award to the legendary Alain F. Carpentier, MD, whose 1983 landmark paper, "Cardiac Valve Surgery – the ‘French Correction,’ " is credited with heralding the modern era of mitral valve reconstructive surgery. Professor Carpentier delivered the Conclave Honored Lecture.

A series of "mini debates" addressed controversies surrounding the use of annuloplasty rings (flexible versus remodeling versus no ring at all), minimally invasive surgery (for all patients versus for some), and the correct approach for specific clinical scenarios of tricuspid valve disease.

The next Aortic Symposium will be held April 26-27, 2012, and the next Mitral Conclave will take place May 2-3, 2013, both in New York. Proceedings from the 2011 Mitral Conclave will be published in an upcoming supplement to The Journal of Thoracic and Cardiovascular Surgery.n

The first-ever AATS Mitral Conclave was held on May 5^th and 6^th. The world’s leading experts in mitral valve disease convened to discuss management guidelines, imaging, pathology, minimally invasive procedures, percutaneous approaches, surgical techniques, devices, and long-term results.

"With 39 faculty and 250 presentations, including selected abstracts and videos, our goal was to have a comprehensive meeting focused on mitral valve disease that would allow attendees to gain exposure to all of the common approaches used in the top centers throughout the world," said Program Director David H. Adams, MD. "We continue to see tremendous progress in our understanding of mitral disease intervention, and a great interest among surgeons in learning and advancing mitral valve repair strategies," said Dr. Adams, chairman of the department of cardiothoracic surgery at the Mount Sinai Medical Center, New York.

More than 1,000 individuals – including about 800 physicians – from 66 countries participated. Industry support was provided by Edwards Lifesciences LLC (Premier Platinum), Metronic, Inc. (Platinum), Abbott Vascular (Gold), Sorin Heart Valves (Gold), and St. Jude Medical Inc. (Bronze).

"I figured we might get 250 physicians, and would have considered that a success. This is fantastic," said AATS President Irving L. Kron, MD.

Presentations included lectures, expert video sessions, and "Presentations on Demand," accessible on video screens positioned in the exhibit hall. In a plenary address, Robert O. Bonow, MD, said that current valvular heart disease guidelines are based largely on expert opinion rather than evidence from clinical trials. Referring to the 2008 revised joint guidelines from the American College of Cardiology/American Heart Association and the 2007 European Society of Cardiology guidelines, he said, "Unfortunately, the evidence base underpinning them is limited by an inadequate number of randomized clinical trials. We really need to provide more evidence-based information to devise true guidelines and performance measures."

The question of whether mitral valve repair should be considered in all patients with severe mitral valve regurgitation is still being debated.

"It’s at least likely that certain patient subsets would benefit, but current data are insufficient to determine which ones," said Dr. Bonow, of Northwestern University. As an example of ambiguity, U.S. guidelines recommend that patients considered eligible for repair be referred to an "experienced center," but don’t provide criteria for determining that status. Moreover, individual surgeon volume and experience clearly predict successful mitral repair outcomes, even within one institution.

Dr. Bonow is optimistic that useful data will come from two ongoing trials sponsored by the National Heart, Lung, and Blood Institute via the Cardiothoracic Surgical Trials Network.

Dr. Adams presented the Mitral Conclave Career Achievement Award to the legendary Alain F. Carpentier, MD, whose 1983 landmark paper, "Cardiac Valve Surgery – the ‘French Correction,’ " is credited with heralding the modern era of mitral valve reconstructive surgery. Professor Carpentier delivered the Conclave Honored Lecture.

A series of "mini debates" addressed controversies surrounding the use of annuloplasty rings (flexible versus remodeling versus no ring at all), minimally invasive surgery (for all patients versus for some), and the correct approach for specific clinical scenarios of tricuspid valve disease.

The next Aortic Symposium will be held April 26-27, 2012, and the next Mitral Conclave will take place May 2-3, 2013, both in New York. Proceedings from the 2011 Mitral Conclave will be published in an upcoming supplement to The Journal of Thoracic and Cardiovascular Surgery.n

SAN ANTONIO – Partial fundoplication improves dysphagia and regurgitation symptom scores in those patients undergoing laparoscopic Heller myotomy for esophageal achalasia, regardless of whether the fundus is laid over the anterior esophagus or wrapped around the back of it, a multicenter study has shown.

Previous studies have demonstrated that partial fundoplication minimizes the likelihood of developing gastroesophageal reflux disease (GERD), but none has systematically compared the risks and benefits associated with wrapping the gastric fundus anterior to the esophagus (Dor fundoplication) or posterior to the esophagus (Toupet fundoplication), Dr. Arthur Rawlings said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

"The type of fundoplication that should be performed is controversial, and currently determined by surgeon’s choice rather than scientific evidence," he said. "Some surgeons advocate the Dor because they say it’s less complicated to perform, [avoids] the need for complete posterior dissection, completely disrupts the posterior esophageal ligament, and does cover the exposed esophageal mucosa." On the other hand, he noted, "other surgeons advocate for a Toupet fundoplication because it keeps the edges of the myotomy separated and possibly provides better reflux control."

To compare symptom frequency and severity as well as physiological differences associated with the two procedures, Dr. Rawlings of Washington University, St. Louis, and his colleagues conducted a multicenter, prospective trial. In all, 85 patients undergoing laparoscopic Heller myotomy at five sites in 2003-2008 were randomized to the Dor or Toupet partial fundoplication. The investigators assessed symptomatic GERD scores based on a 5-point (0-4) Likert scale preoperatively and at 2-6 weeks, 6 months, and 12 months postoperatively. They also evaluated 24-hour pH testing at 6-12 months, calculating the percentage of total pH time less than 4 and a composite DeMeester pH score, he said.

Both groups had similar age, sex distribution, and illness characteristics. The researchers obtained 6- to 12-month pH studies for 24 of the 49 patients who were randomized to the Dor procedure and 19 of the 36 patients who were randomized to the Toupet procedure, Dr. Rawlings said. The results reported at the meeting represent those obtained for the patients for whom pH-testing results were available, he explained.

In both groups, dysphagia and regurgitation symptom frequency and severity scores improved substantially, compared with preoperative measures, Dr. Rawlings said. "Statistically significant improvements were observed in both groups for all but heartburn and chest pain measures," he noted. Specifically, in the Dor group, the preoperative solid dysphagia, heartburn, and regurgitation scores of 3.0, 1.5, and 2.8, respectively, improved to 1.3, 0.7, and 0.7 at 6 months, and the preoperative scores in the Toupet group of 3.1, 1.0, and 3.3 improved to 1.0, 0.3, and 0.1, respectively, he said.

There was no significant difference between the two groups with respect to DeMeester pH scores or the percentage of pH time less than 4, although abnormal acid reflux was experienced by 42% of the Dor patients and just 21% of the Toupet patients, said Dr. Rawlings. The difference between the median DeMeester pH scores at 6 months for the Dor (7.2) and Toupet (2.2) groups did not reach statistical significance, he said.

In a subgroup analysis of individuals with abnormal reflux scores regardless of fundoplication procedure, "the only thing that fell out as significant was heartburn frequency and severity," Dr. Rawlings stated.

The findings indicate that both the Dor and Toupet procedures following Heller myotomy produce comparable decreases in reflux symptoms and improvements in quality of life, according to Dr. Rawlings. The differences in pathological acid reflux between the two groups, though not statistically significant, "do support the use of pH testing following Heller myotomy for detecting abnormal esophageal acid exposure," he said.

This study was supported a SAGES research grant. Dr. Rawlings disclosed financial relationships with Lifecell Corp. and Cook Medical.☐

SAN ANTONIO – Partial fundoplication improves dysphagia and regurgitation symptom scores in those patients undergoing laparoscopic Heller myotomy for esophageal achalasia, regardless of whether the fundus is laid over the anterior esophagus or wrapped around the back of it, a multicenter study has shown.

Previous studies have demonstrated that partial fundoplication minimizes the likelihood of developing gastroesophageal reflux disease (GERD), but none has systematically compared the risks and benefits associated with wrapping the gastric fundus anterior to the esophagus (Dor fundoplication) or posterior to the esophagus (Toupet fundoplication), Dr. Arthur Rawlings said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

"The type of fundoplication that should be performed is controversial, and currently determined by surgeon’s choice rather than scientific evidence," he said. "Some surgeons advocate the Dor because they say it’s less complicated to perform, [avoids] the need for complete posterior dissection, completely disrupts the posterior esophageal ligament, and does cover the exposed esophageal mucosa." On the other hand, he noted, "other surgeons advocate for a Toupet fundoplication because it keeps the edges of the myotomy separated and possibly provides better reflux control."

To compare symptom frequency and severity as well as physiological differences associated with the two procedures, Dr. Rawlings of Washington University, St. Louis, and his colleagues conducted a multicenter, prospective trial. In all, 85 patients undergoing laparoscopic Heller myotomy at five sites in 2003-2008 were randomized to the Dor or Toupet partial fundoplication. The investigators assessed symptomatic GERD scores based on a 5-point (0-4) Likert scale preoperatively and at 2-6 weeks, 6 months, and 12 months postoperatively. They also evaluated 24-hour pH testing at 6-12 months, calculating the percentage of total pH time less than 4 and a composite DeMeester pH score, he said.

Both groups had similar age, sex distribution, and illness characteristics. The researchers obtained 6- to 12-month pH studies for 24 of the 49 patients who were randomized to the Dor procedure and 19 of the 36 patients who were randomized to the Toupet procedure, Dr. Rawlings said. The results reported at the meeting represent those obtained for the patients for whom pH-testing results were available, he explained.

In both groups, dysphagia and regurgitation symptom frequency and severity scores improved substantially, compared with preoperative measures, Dr. Rawlings said. "Statistically significant improvements were observed in both groups for all but heartburn and chest pain measures," he noted. Specifically, in the Dor group, the preoperative solid dysphagia, heartburn, and regurgitation scores of 3.0, 1.5, and 2.8, respectively, improved to 1.3, 0.7, and 0.7 at 6 months, and the preoperative scores in the Toupet group of 3.1, 1.0, and 3.3 improved to 1.0, 0.3, and 0.1, respectively, he said.

There was no significant difference between the two groups with respect to DeMeester pH scores or the percentage of pH time less than 4, although abnormal acid reflux was experienced by 42% of the Dor patients and just 21% of the Toupet patients, said Dr. Rawlings. The difference between the median DeMeester pH scores at 6 months for the Dor (7.2) and Toupet (2.2) groups did not reach statistical significance, he said.

In a subgroup analysis of individuals with abnormal reflux scores regardless of fundoplication procedure, "the only thing that fell out as significant was heartburn frequency and severity," Dr. Rawlings stated.

The findings indicate that both the Dor and Toupet procedures following Heller myotomy produce comparable decreases in reflux symptoms and improvements in quality of life, according to Dr. Rawlings. The differences in pathological acid reflux between the two groups, though not statistically significant, "do support the use of pH testing following Heller myotomy for detecting abnormal esophageal acid exposure," he said.

This study was supported a SAGES research grant. Dr. Rawlings disclosed financial relationships with Lifecell Corp. and Cook Medical.☐

SAN ANTONIO – Partial fundoplication improves dysphagia and regurgitation symptom scores in those patients undergoing laparoscopic Heller myotomy for esophageal achalasia, regardless of whether the fundus is laid over the anterior esophagus or wrapped around the back of it, a multicenter study has shown.

Previous studies have demonstrated that partial fundoplication minimizes the likelihood of developing gastroesophageal reflux disease (GERD), but none has systematically compared the risks and benefits associated with wrapping the gastric fundus anterior to the esophagus (Dor fundoplication) or posterior to the esophagus (Toupet fundoplication), Dr. Arthur Rawlings said at the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

"The type of fundoplication that should be performed is controversial, and currently determined by surgeon’s choice rather than scientific evidence," he said. "Some surgeons advocate the Dor because they say it’s less complicated to perform, [avoids] the need for complete posterior dissection, completely disrupts the posterior esophageal ligament, and does cover the exposed esophageal mucosa." On the other hand, he noted, "other surgeons advocate for a Toupet fundoplication because it keeps the edges of the myotomy separated and possibly provides better reflux control."

To compare symptom frequency and severity as well as physiological differences associated with the two procedures, Dr. Rawlings of Washington University, St. Louis, and his colleagues conducted a multicenter, prospective trial. In all, 85 patients undergoing laparoscopic Heller myotomy at five sites in 2003-2008 were randomized to the Dor or Toupet partial fundoplication. The investigators assessed symptomatic GERD scores based on a 5-point (0-4) Likert scale preoperatively and at 2-6 weeks, 6 months, and 12 months postoperatively. They also evaluated 24-hour pH testing at 6-12 months, calculating the percentage of total pH time less than 4 and a composite DeMeester pH score, he said.

Both groups had similar age, sex distribution, and illness characteristics. The researchers obtained 6- to 12-month pH studies for 24 of the 49 patients who were randomized to the Dor procedure and 19 of the 36 patients who were randomized to the Toupet procedure, Dr. Rawlings said. The results reported at the meeting represent those obtained for the patients for whom pH-testing results were available, he explained.

In both groups, dysphagia and regurgitation symptom frequency and severity scores improved substantially, compared with preoperative measures, Dr. Rawlings said. "Statistically significant improvements were observed in both groups for all but heartburn and chest pain measures," he noted. Specifically, in the Dor group, the preoperative solid dysphagia, heartburn, and regurgitation scores of 3.0, 1.5, and 2.8, respectively, improved to 1.3, 0.7, and 0.7 at 6 months, and the preoperative scores in the Toupet group of 3.1, 1.0, and 3.3 improved to 1.0, 0.3, and 0.1, respectively, he said.

There was no significant difference between the two groups with respect to DeMeester pH scores or the percentage of pH time less than 4, although abnormal acid reflux was experienced by 42% of the Dor patients and just 21% of the Toupet patients, said Dr. Rawlings. The difference between the median DeMeester pH scores at 6 months for the Dor (7.2) and Toupet (2.2) groups did not reach statistical significance, he said.

In a subgroup analysis of individuals with abnormal reflux scores regardless of fundoplication procedure, "the only thing that fell out as significant was heartburn frequency and severity," Dr. Rawlings stated.

The findings indicate that both the Dor and Toupet procedures following Heller myotomy produce comparable decreases in reflux symptoms and improvements in quality of life, according to Dr. Rawlings. The differences in pathological acid reflux between the two groups, though not statistically significant, "do support the use of pH testing following Heller myotomy for detecting abnormal esophageal acid exposure," he said.

This study was supported a SAGES research grant. Dr. Rawlings disclosed financial relationships with Lifecell Corp. and Cook Medical.☐

Note: The definitions of ‘first’ and ‘success­ful’ can be contentious in any branch of his­tory.The history of medicine is no exception. The dates and events listed below have at least some legitimate consensus behind them.

1893 First documented successful peri­cardium repair (Daniel Hale Williams)

1896 First successful heart operation (Ludwig Rehn).

1924 First successful pulmonary em­bolectomy (Martin Kirshner).

1937 Congenital heart surgery ‘begins’ with ductus ligation procedure (John Streider).

1938 First ductus ligation leading to full recovery (Robert Gross).

1945 Blalock-Taussig operation for ‘blue baby syndrome’ (Alfred Blalock/Helen Taussig).

1946 First anomalous coronary artery re­pair (Viking Olov Biorck/Clarence Crafoord).

1947 First successful pulmonary valvo­tomy (Thomas Holmes Sellers).

1948 First successful mitral commis­surotomy (Charles Bailey).

1952 First successful right-sided heart bypass (Forest Dodrill).

1953 First complete atrioventricular canal using cross-circulation (C. Walton Lillehei).

1954 First Tetralogy of Fallot repair us­ing cardiopulmonary bypass (John Kirklin).

1962 First pulmonary embolectomy us­ing cardiopulmonary bypass (Edward Sharp).

1968 First successful cardiac arrhythmia surgery (Will C. Sealy).

I have checked the following facts in my story: (Please initial each.)

Compiled from the following source:

“History of Cardiac Surgery,” Larry W. Stephenson, in Lawrence H. Cohn, (ed) <[lb]>“Cardiac Surgery in the Adult.”

Note: The definitions of ‘first’ and ‘success­ful’ can be contentious in any branch of his­tory.The history of medicine is no exception. The dates and events listed below have at least some legitimate consensus behind them.

1893 First documented successful peri­cardium repair (Daniel Hale Williams)

1896 First successful heart operation (Ludwig Rehn).

1924 First successful pulmonary em­bolectomy (Martin Kirshner).

1937 Congenital heart surgery ‘begins’ with ductus ligation procedure (John Streider).

1938 First ductus ligation leading to full recovery (Robert Gross).

1945 Blalock-Taussig operation for ‘blue baby syndrome’ (Alfred Blalock/Helen Taussig).

1946 First anomalous coronary artery re­pair (Viking Olov Biorck/Clarence Crafoord).

1947 First successful pulmonary valvo­tomy (Thomas Holmes Sellers).

1948 First successful mitral commis­surotomy (Charles Bailey).

1952 First successful right-sided heart bypass (Forest Dodrill).

1953 First complete atrioventricular canal using cross-circulation (C. Walton Lillehei).

1954 First Tetralogy of Fallot repair us­ing cardiopulmonary bypass (John Kirklin).

1962 First pulmonary embolectomy us­ing cardiopulmonary bypass (Edward Sharp).

1968 First successful cardiac arrhythmia surgery (Will C. Sealy).

I have checked the following facts in my story: (Please initial each.)

Compiled from the following source:

“History of Cardiac Surgery,” Larry W. Stephenson, in Lawrence H. Cohn, (ed) <[lb]>“Cardiac Surgery in the Adult.”

Note: The definitions of ‘first’ and ‘success­ful’ can be contentious in any branch of his­tory.The history of medicine is no exception. The dates and events listed below have at least some legitimate consensus behind them.

1893 First documented successful peri­cardium repair (Daniel Hale Williams)

1896 First successful heart operation (Ludwig Rehn).

1924 First successful pulmonary em­bolectomy (Martin Kirshner).

1937 Congenital heart surgery ‘begins’ with ductus ligation procedure (John Streider).

1938 First ductus ligation leading to full recovery (Robert Gross).

1945 Blalock-Taussig operation for ‘blue baby syndrome’ (Alfred Blalock/Helen Taussig).

1946 First anomalous coronary artery re­pair (Viking Olov Biorck/Clarence Crafoord).

1947 First successful pulmonary valvo­tomy (Thomas Holmes Sellers).

1948 First successful mitral commis­surotomy (Charles Bailey).

1952 First successful right-sided heart bypass (Forest Dodrill).

1953 First complete atrioventricular canal using cross-circulation (C. Walton Lillehei).

1954 First Tetralogy of Fallot repair us­ing cardiopulmonary bypass (John Kirklin).

1962 First pulmonary embolectomy us­ing cardiopulmonary bypass (Edward Sharp).

1968 First successful cardiac arrhythmia surgery (Will C. Sealy).

I have checked the following facts in my story: (Please initial each.)

Compiled from the following source:

“History of Cardiac Surgery,” Larry W. Stephenson, in Lawrence H. Cohn, (ed) <[lb]>“Cardiac Surgery in the Adult.”

What makes a Cardiothoracic training program great? For many it means that the program “leads” the field in surgical knowledge, blazing a path towards discovery. To oth­ers it means the program trains future surgeons well by teaching them how to operate. Still others feel it is a program with a rich history and an esteemed group of surgeons on its board …the list could go on and on. The Joint Council on Thoracic Surgery Education (JCTSE) recently has begun to focus on identify­ing areas within surgical education that makes a program stand above the rest.

To some, searching for what makes a Cardiothoracic program “great” is pure­ly subjective like a quest for the world’s greatest donut. The goal here is not to form a simple rank list of the most out­standing CT programs; rather, the JCTSE aims to identify traits of pro­grams that support the American Board of Thoracic Surgery’s mission to “pro­tect the public by establishing and main­
taining high standards in thoracic surgery.” The mere ranking of programs in a neat and orderly line likely does not hold much educational purpose. The identification of “great” traits though, does have purpose and will help deliver specific goals from broad educational principals.

The JCTSE and the Thoracic Surgery Residents Association (TSRA) have re­cently taken a first step in collecting these traits of greatness by sending out
a preliminary survey to current cardio­thoracic (CT) residents. The survey con­sisted of 50 questions addressing the relative importance of multiple aspects of CT surgery training programs and ini­tial findings varied from the expected to the surprising. Traditional areas of im­portance such as the reputation of the program, the expectation of trainees functioning as operating surgeon, help in finding employment and a high volume and complexity of cases were at the top
of the list. Surprisingly, other areas queried such as the program’s facilities or if the program is 2 or 3 years were not felt to be important in making a program “outstanding” by current CT residents.

Now that this preliminary data has been collected, a more scientific survey is being developed to administer to fu­ture generations of CT residents. The data from which may ultimately serve as a useful guide to “raise all boats” towards greatness in Cardiothoracic training.

What makes a Cardiothoracic training program great? For many it means that the program “leads” the field in surgical knowledge, blazing a path towards discovery. To oth­ers it means the program trains future surgeons well by teaching them how to operate. Still others feel it is a program with a rich history and an esteemed group of surgeons on its board …the list could go on and on. The Joint Council on Thoracic Surgery Education (JCTSE) recently has begun to focus on identify­ing areas within surgical education that makes a program stand above the rest.

To some, searching for what makes a Cardiothoracic program “great” is pure­ly subjective like a quest for the world’s greatest donut. The goal here is not to form a simple rank list of the most out­standing CT programs; rather, the JCTSE aims to identify traits of pro­grams that support the American Board of Thoracic Surgery’s mission to “pro­tect the public by establishing and main­
taining high standards in thoracic surgery.” The mere ranking of programs in a neat and orderly line likely does not hold much educational purpose. The identification of “great” traits though, does have purpose and will help deliver specific goals from broad educational principals.

The JCTSE and the Thoracic Surgery Residents Association (TSRA) have re­cently taken a first step in collecting these traits of greatness by sending out
a preliminary survey to current cardio­thoracic (CT) residents. The survey con­sisted of 50 questions addressing the relative importance of multiple aspects of CT surgery training programs and ini­tial findings varied from the expected to the surprising. Traditional areas of im­portance such as the reputation of the program, the expectation of trainees functioning as operating surgeon, help in finding employment and a high volume and complexity of cases were at the top
of the list. Surprisingly, other areas queried such as the program’s facilities or if the program is 2 or 3 years were not felt to be important in making a program “outstanding” by current CT residents.

Now that this preliminary data has been collected, a more scientific survey is being developed to administer to fu­ture generations of CT residents. The data from which may ultimately serve as a useful guide to “raise all boats” towards greatness in Cardiothoracic training.

What makes a Cardiothoracic training program great? For many it means that the program “leads” the field in surgical knowledge, blazing a path towards discovery. To oth­ers it means the program trains future surgeons well by teaching them how to operate. Still others feel it is a program with a rich history and an esteemed group of surgeons on its board …the list could go on and on. The Joint Council on Thoracic Surgery Education (JCTSE) recently has begun to focus on identify­ing areas within surgical education that makes a program stand above the rest.

To some, searching for what makes a Cardiothoracic program “great” is pure­ly subjective like a quest for the world’s greatest donut. The goal here is not to form a simple rank list of the most out­standing CT programs; rather, the JCTSE aims to identify traits of pro­grams that support the American Board of Thoracic Surgery’s mission to “pro­tect the public by establishing and main­
taining high standards in thoracic surgery.” The mere ranking of programs in a neat and orderly line likely does not hold much educational purpose. The identification of “great” traits though, does have purpose and will help deliver specific goals from broad educational principals.

The JCTSE and the Thoracic Surgery Residents Association (TSRA) have re­cently taken a first step in collecting these traits of greatness by sending out
a preliminary survey to current cardio­thoracic (CT) residents. The survey con­sisted of 50 questions addressing the relative importance of multiple aspects of CT surgery training programs and ini­tial findings varied from the expected to the surprising. Traditional areas of im­portance such as the reputation of the program, the expectation of trainees functioning as operating surgeon, help in finding employment and a high volume and complexity of cases were at the top
of the list. Surprisingly, other areas queried such as the program’s facilities or if the program is 2 or 3 years were not felt to be important in making a program “outstanding” by current CT residents.

Now that this preliminary data has been collected, a more scientific survey is being developed to administer to fu­ture generations of CT residents. The data from which may ultimately serve as a useful guide to “raise all boats” towards greatness in Cardiothoracic training.

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

SAN FRANCISCO – Endo­scopic resection may help man­agement of clinically node– negative superficial squamous cell carcinoma of the esophagus, new data from Japan suggest.

<[stk -1]>A retrospective study of 83 patients who had endoscopic re­section and subsequent treat­ment because of the depth of cancer invasion found a 5-year survival rate of 76% when fol­lowed by chemoradiation and 100% when followed by surgery.<[etk]>

<[stk -1]>The most common complica­tion of the endoscopic resection was stenosis, noted in 11% of cases overall, lead investigator Dr. Toshiro Iizuka, a gastroen­terologist at Toranomon Hospi­tal in Tokyo, reported at the meeting  on gastrointestinal can­cers sponsored by the American Society of Clinical Oncology.

“Endoscopic therapy plus ad­ditional treatment for M3 to SM2 superficial carcinoma of the esophagus did not entail the development of any serious complications. Thus, such com­bined treatment was safe and feasible,” Dr. Iizuka comment­ed. “The long-term follow-up results were fairly gratifying.”

“Surgical resection has been considered as a standard treat­ment in cases of superficial esophageal cancer with poten­tial lymph node metastasis,” but up to two-thirds of patients ex­perience serious complications.

<[stk -1]>“The frequency of lymph node metastases in superficial squamous cell carcinoma of the esophagus … depends on the depth of invasion,” said Dr. Iizu­ka. “Accordingly, a therapeutic strategy has become feasible whereby endoscopic submucos­al dissection aimed at local con­trol is undertaken first, followed by considering additional treat­ment based on the results of the histological examination.”<[etk]>

<[stk -1]>The patients all had T1 tu­mors and clinically node-nega­tive (cN0) status as determined by endoscopy, endoscopic ultra­sound, CT, and PET imaging. They had endoscopic resection, either endoscopic mucosal re­section (EMR) before March 2005 or endoscopic submucosal dissection (ESD) after.<[etk]>

<[stk -3]>Histologic evaluation of the endoscopically resected lesions showed that 140 patients had pathologic M3, SM1, or SM2 tu­mors, and they therefore received additional treatment. Patients found to have pathologic M1 or M2 tumors were followed.<[etk]>

Dr. Iizuka focused on results for 27 patients who underwent subsequent surgical resection and 56 who underwent subse­quent chemoradiation, with the choice between these two op­tions left to patients after dis­cussion of each in their case.

Overall, these patients had a mean age of about 63 years, and 87% were men. Tumors were roughly equally located in the upper, middle, and lower esophagus; the mean size was 42 mm in the surgery group and 26 mm in the chemoradia­tion group. The majority of en­doscopic resections were ESD.

In the surgery group, patients more often had a three-field lymph node dissection (59%) than a two-field one (41%). In the chemoradiation group, the majority of patients received 40-45 Gy of radiation (86%) and low-dose 5-fluorouracil and cis­platin chemotherapy (57%).

Results for all 140 patients who underwent endoscopic re­section showed a resection rate of 81% and an R0 resection rate of 72%. Overall, 15% of pa­tients had a complication from the procedure, with stenosis, at 11%, being the most common.

The main complications were anastomotic stenosis (15% of patients) and recurrent nerve palsy (7%). Also, 7% of patients were found to have residual can­cer and 4% were found to have lymph node metastases. The main serious complication of chemoradiation was grade 3 leukopenia (14%). There were no treatment-related deaths or grade 4 adverse events.

The median duration of fol­low-up was 42.5 months in the surgery group and 33 months in the chemoradiation group.

None of the patients had a lo­cal recurrence. The actuarial 5-year rates of relapse-free survival were 100% and 88%, re­spectively; the actuarial 5-year rates of overall survival were 100% and 76%, respectively.

Dr. Iizuka reported no rele­vant conflicts of interest.

SAN FRANCISCO – Endo­scopic resection may help man­agement of clinically node– negative superficial squamous cell carcinoma of the esophagus, new data from Japan suggest.

<[stk -1]>A retrospective study of 83 patients who had endoscopic re­section and subsequent treat­ment because of the depth of cancer invasion found a 5-year survival rate of 76% when fol­lowed by chemoradiation and 100% when followed by surgery.<[etk]>

<[stk -1]>The most common complica­tion of the endoscopic resection was stenosis, noted in 11% of cases overall, lead investigator Dr. Toshiro Iizuka, a gastroen­terologist at Toranomon Hospi­tal in Tokyo, reported at the meeting  on gastrointestinal can­cers sponsored by the American Society of Clinical Oncology.

“Endoscopic therapy plus ad­ditional treatment for M3 to SM2 superficial carcinoma of the esophagus did not entail the development of any serious complications. Thus, such com­bined treatment was safe and feasible,” Dr. Iizuka comment­ed. “The long-term follow-up results were fairly gratifying.”

“Surgical resection has been considered as a standard treat­ment in cases of superficial esophageal cancer with poten­tial lymph node metastasis,” but up to two-thirds of patients ex­perience serious complications.

<[stk -1]>“The frequency of lymph node metastases in superficial squamous cell carcinoma of the esophagus … depends on the depth of invasion,” said Dr. Iizu­ka. “Accordingly, a therapeutic strategy has become feasible whereby endoscopic submucos­al dissection aimed at local con­trol is undertaken first, followed by considering additional treat­ment based on the results of the histological examination.”<[etk]>

<[stk -1]>The patients all had T1 tu­mors and clinically node-nega­tive (cN0) status as determined by endoscopy, endoscopic ultra­sound, CT, and PET imaging. They had endoscopic resection, either endoscopic mucosal re­section (EMR) before March 2005 or endoscopic submucosal dissection (ESD) after.<[etk]>

<[stk -3]>Histologic evaluation of the endoscopically resected lesions showed that 140 patients had pathologic M3, SM1, or SM2 tu­mors, and they therefore received additional treatment. Patients found to have pathologic M1 or M2 tumors were followed.<[etk]>

Dr. Iizuka focused on results for 27 patients who underwent subsequent surgical resection and 56 who underwent subse­quent chemoradiation, with the choice between these two op­tions left to patients after dis­cussion of each in their case.

Overall, these patients had a mean age of about 63 years, and 87% were men. Tumors were roughly equally located in the upper, middle, and lower esophagus; the mean size was 42 mm in the surgery group and 26 mm in the chemoradia­tion group. The majority of en­doscopic resections were ESD.

In the surgery group, patients more often had a three-field lymph node dissection (59%) than a two-field one (41%). In the chemoradiation group, the majority of patients received 40-45 Gy of radiation (86%) and low-dose 5-fluorouracil and cis­platin chemotherapy (57%).

Results for all 140 patients who underwent endoscopic re­section showed a resection rate of 81% and an R0 resection rate of 72%. Overall, 15% of pa­tients had a complication from the procedure, with stenosis, at 11%, being the most common.

The main complications were anastomotic stenosis (15% of patients) and recurrent nerve palsy (7%). Also, 7% of patients were found to have residual can­cer and 4% were found to have lymph node metastases. The main serious complication of chemoradiation was grade 3 leukopenia (14%). There were no treatment-related deaths or grade 4 adverse events.

The median duration of fol­low-up was 42.5 months in the surgery group and 33 months in the chemoradiation group.

None of the patients had a lo­cal recurrence. The actuarial 5-year rates of relapse-free survival were 100% and 88%, re­spectively; the actuarial 5-year rates of overall survival were 100% and 76%, respectively.

Dr. Iizuka reported no rele­vant conflicts of interest.

SAN FRANCISCO – Endo­scopic resection may help man­agement of clinically node– negative superficial squamous cell carcinoma of the esophagus, new data from Japan suggest.

<[stk -1]>A retrospective study of 83 patients who had endoscopic re­section and subsequent treat­ment because of the depth of cancer invasion found a 5-year survival rate of 76% when fol­lowed by chemoradiation and 100% when followed by surgery.<[etk]>

<[stk -1]>The most common complica­tion of the endoscopic resection was stenosis, noted in 11% of cases overall, lead investigator Dr. Toshiro Iizuka, a gastroen­terologist at Toranomon Hospi­tal in Tokyo, reported at the meeting  on gastrointestinal can­cers sponsored by the American Society of Clinical Oncology.

“Endoscopic therapy plus ad­ditional treatment for M3 to SM2 superficial carcinoma of the esophagus did not entail the development of any serious complications. Thus, such com­bined treatment was safe and feasible,” Dr. Iizuka comment­ed. “The long-term follow-up results were fairly gratifying.”

“Surgical resection has been considered as a standard treat­ment in cases of superficial esophageal cancer with poten­tial lymph node metastasis,” but up to two-thirds of patients ex­perience serious complications.

<[stk -1]>“The frequency of lymph node metastases in superficial squamous cell carcinoma of the esophagus … depends on the depth of invasion,” said Dr. Iizu­ka. “Accordingly, a therapeutic strategy has become feasible whereby endoscopic submucos­al dissection aimed at local con­trol is undertaken first, followed by considering additional treat­ment based on the results of the histological examination.”<[etk]>

<[stk -1]>The patients all had T1 tu­mors and clinically node-nega­tive (cN0) status as determined by endoscopy, endoscopic ultra­sound, CT, and PET imaging. They had endoscopic resection, either endoscopic mucosal re­section (EMR) before March 2005 or endoscopic submucosal dissection (ESD) after.<[etk]>

<[stk -3]>Histologic evaluation of the endoscopically resected lesions showed that 140 patients had pathologic M3, SM1, or SM2 tu­mors, and they therefore received additional treatment. Patients found to have pathologic M1 or M2 tumors were followed.<[etk]>

Dr. Iizuka focused on results for 27 patients who underwent subsequent surgical resection and 56 who underwent subse­quent chemoradiation, with the choice between these two op­tions left to patients after dis­cussion of each in their case.

Overall, these patients had a mean age of about 63 years, and 87% were men. Tumors were roughly equally located in the upper, middle, and lower esophagus; the mean size was 42 mm in the surgery group and 26 mm in the chemoradia­tion group. The majority of en­doscopic resections were ESD.

In the surgery group, patients more often had a three-field lymph node dissection (59%) than a two-field one (41%). In the chemoradiation group, the majority of patients received 40-45 Gy of radiation (86%) and low-dose 5-fluorouracil and cis­platin chemotherapy (57%).

Results for all 140 patients who underwent endoscopic re­section showed a resection rate of 81% and an R0 resection rate of 72%. Overall, 15% of pa­tients had a complication from the procedure, with stenosis, at 11%, being the most common.

The main complications were anastomotic stenosis (15% of patients) and recurrent nerve palsy (7%). Also, 7% of patients were found to have residual can­cer and 4% were found to have lymph node metastases. The main serious complication of chemoradiation was grade 3 leukopenia (14%). There were no treatment-related deaths or grade 4 adverse events.

The median duration of fol­low-up was 42.5 months in the surgery group and 33 months in the chemoradiation group.

None of the patients had a lo­cal recurrence. The actuarial 5-year rates of relapse-free survival were 100% and 88%, re­spectively; the actuarial 5-year rates of overall survival were 100% and 76%, respectively.

Dr. Iizuka reported no rele­vant conflicts of interest.

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest. 

DETROIT – Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 sur­geons over the next 20 years.

“We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bid­ding wars,” Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.

“In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today.”

The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical spe­cialties: obstetrics and gynecology, or­thopedic surgery, general surgery, otolaryngology, urology, neurosurgery,
and thoracic surgery (Ann. Surg. 2009;250:590-7). I’ve searched and can’t find the print reference. Help?—EW The trick is to search by the article name in Google. I got abut 5 different versions that way./CNW»

The current analysis went one step fur­ther, focusing on the average recruit­ment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population re­ceiving care at urban and rural hospitals will remain constant, Dr. Williams ex­plained.

Currently, the American Hospital As­sociation estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hos­pitals serving 18% or 56 million Ameri­cans.

Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and re­tain 4,175 surgeons per year or 27.7 sur­geons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams «not facs»of the department of surgery at Ohio State University in Columbus.

While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dra­matic loss of general surgeons.

“In rural hospitals, general surgery is essential,” he said. “[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their ad­ministrators of retiring or leaving in 2 years. Thirty-three percent of rural hos­pitals are recruiting now.”

Factors that might make rural re­cruitment more difficult include profes­sional and social isolation, cross coverage, insufficient training for the va­riety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.

Factors that positively influence rural recruitment include the chance to be a critical part of the community, indepen­dence, the wide spectrum of procedures, and hailing from a rural area.

One strategy that can tip a surgeon to­ward a rural hospital is doing a residen­cy in a rural training program. The researchers estimate that half of gener­al surgery residents who rotate through such a program will go on to practice in rural towns.

“It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals,” Dr. Williams said.

Consideration of the needs of the sur­geon’s family is another factor. Typical­
ly, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician cou­ple. Thus, educational loan repayment could be a potential “trump card” for rur­al hospitals in the future, he said.

Rural hospitals are already throw­ing out the wel­come mat. Most offer hiring incen­tives such as a re­location allowance; signing bonus; health, dis­ability, and life in­surance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hos­pitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.

“In many general surgery programs in the United States, senior residents are re­ceiving as many as 50 offers for employ­ment today,” he said.

To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an or­thopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full ben­efits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.

Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.

Invited discussant Dr. Nathaniel Sop­er, «facs»chair of the department of surgery at Northwestern University in Chicago, said, “It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done.”

Dr. Sober suggested that the basic problem is not so much the division be­tween rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.

Co-author and colleague Dr. Bhag­wan Satiani replied that the analysis in­cluded a simplified version of the federal model used to calculate supply and de­mand, but added that every projection in the last 50-75 years has been wrong. “You have to look at this model and say, ‘This is the best we can do right now,” he said.

According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive med­ical school rural program (MSRP). “If you took 10 medical students out of the class and put them into the MSRP pro­
gram, you could double the number of rural surgeons. That’s how important that is,” said Dr. Satiani, «facs»medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.

A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia pro­vides a similar cal­culation for rural physicians and re­ports that 79%-87% of graduates from the two MSRPs with long-range rural out­comes – the PSAP and University of Minnesota at Duluth – remained in rur­al practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Af­fordable Care Act authorized a new Rur­al Physician Training Grants program to provide grants to medical schools to de­velop or expand MSRPs.

Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be consid­ered programs that attract rural sur­geons, according to Dr. Satiani. “I think American surgery is going to have to give this a separate tract within residency programs.”

Audience member Dr. Mark Malan­goni, «facs»associate executive director of the American Board of Surgery in Philadel­phia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Wash­ington state.

He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.

If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural ar­eas.

Finally, several audience members sug­gested that efforts need to be made to eliminate the perception among resi­dents that surgical specialists are some­how better than general surgeons.

“It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists,” Dr. Satiani said. “I think it has to come from the programs and the leadership; defin­ing general surgery better, even going as far as changing the name, if that be­comes an important issue.”

When asked in an interview what that new name might be, Dr. Satiani said the terms “master surgeon” and “omni sur­geon” have been floated, with master surgeon more likely to resonate with the general public.

I have checked the following facts in my story: (Please initial each.)

The authors reported no conflicts of interest.