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What is the Future of Surgery in the UK?
LEADING ARTICLE
the future, and those that are performed will be by laparoscopic techniques, while the majority of patients will be treated by endovascular means.
What is the Future of Surgery in the UK?
Gastrointestinal disease Vagotomy, pyloroplasty and gastrectomy have virtually disappeared from the menu of operations performed today, except perhaps for the treatment of perforated duodenal ulcer. These procedures were among the most commonly performed in general surgery, and many surgeons learnt their trade carrying out these operations. It is probable that carcinoma of the gastrointestinal tract (which accounts for a good deal of the workload of gastrointestinal surgeons) will diminish, particularly if a cure for cancer or the improving efficiency of chemotherapy comes to fruition. A number of operations currently performed, for example, to avoid gastric reflux or to remove gall bladders, will also be under threat, if the cause of these conditions becomes apparent and drug therapy prevents their occurrence. Emergency surgery following trauma of the abdomen may be all that is left to occupy the gastrointestinal surgeon. Trauma will still occur and the ability to staff hospitals with an adequate number of surgeons who have enough elective duties while providing an emergency rota will be made more difficult.
Professor Sir Peter Bell
Surgery is an invasive form of treatment and must be a ‘last resort’. Research into conditions that can be treated by surgery aims to make it extinct, by discovering the basis for various disease processes and treating them medically. A prime example of this is peptic ulceration, which was the ‘bread and butter’ of surgical training in the UK in the 1970s and 1980s, but is now a condition that has almost vanished from the surgical lexicon with the discovery of Helicobacter pylori and its treatment by triple therapy and proton pump inhibitors. In the ‘molecular age’, there is a strong possibility that other areas of surgery (which currently keep many surgeons occupied) will also diminish in volume and importance. Further, it would be worth looking briefly at a number of different specialties within surgery and speculating where changes may occur in the future, perhaps making operations less necessary. In those areas where molecular advances have not (or will not) eradicate open surgery, there will be a definite tendency towards minimally invasive procedures, even though the introduction of such procedures is seldom evidence based.
Urological surgery The urologist already performs a lot of necessary work through a cystoscope. Open operations on the kidney are decreasing in frequency as stones are broken down by lithotripsy and laparoscopic renal procedures are performed more often. Drugs can shrink the prostate without the need for surgery, and prostate cancer (along with bladder cancer) is better understood. It is likely that if cures for these cancers are found, it will be less necessary for urological surgeons to operate at all.
Vascular surgery Vascular surgery has had a relatively short history, originating in the late 1950s and flourishing in the 1960s–80s. The advent of interventional activities (made possible by advances in technology) has meant that the number of operations for conditions such as aortic aneurysm and arterial bypass grafting has progressively diminished on a yearly basis, as interventional procedures have increased. Recently, the frequently performed operation of carotid endarterectomy (which is supported by randomized studies) has come under threat from carotid angioplasty, which seems to work quite well, particularly if a protective device to prevent embolization is used. At present, use of this technique is not evidence based, but if it is successful, will mean the demise of carotid surgery in the long-term. Although there is little evidence that such procedures are better than open operations, patients prefer them because of the relative lack of trauma. Because of these changes, the number of open vascular procedures has diminished progressively in recent years. Also, the reduction in smoking and the emergence of statins and allied drugs may mean that the disease process (atheroma) is becoming less common. It is likely that fewer open vascular operations will be necessary in
Cardiopulmonary surgery If cancer is controlled and smoking diminishes, the need for lung surgery will lessen considerably. The requirement to perform coronary artery bypass grafting is diminishing already, as balloon dilatation and the ability to insert stents increases. The invention of drug-coated stents (which have been shown to reduce intimal hyperplasia and restenosis) will make further inroads in the need to perform open surgery. The remaining operations will be performed by minimally invasive techniques and operations on the beating heart will become more common and carried out in fewer centres. Even heart transplantation is at risk, with progress being made towards the injection of stem cells into the myocardium, which then differentiate into functional heart muscle, thereby improving cardiac activity. Congenital valve problems will probably still continue, although they will be less in number because of improved antepartum screening. Ear, nose and throat (ENT) and maxillofacial surgery The improvement in medical treatment and a better understanding of the underlying disease processes which ENT and maxillofacial surgeons encounter will lead to a reduction in activity in these areas. Reconstructive surgery for excision of cancers will also diminish if a cure for cancer is found or chemotherapy improves. Problems will still occur, but the maxillofacial and ENT surgeons may well be left with trauma as their main source
Peter R F Bell is the Foundation Professor of Surgery at Leicester University, Leicester, UK. He qualified from Sheffield University and trained in surgery in Sheffield, Glasgow, UK, and Denver, USA. His interests are vascular surgery and transplantation.
SURGERY
i
© 2003 The Medicine Publishing Company Ltd
LEADING ARTICLE
of operative activity and, as in other specialties, many fewer surgeons will be required.
will deal with the peripheral, arterial or venous system, some performing interventional procedures and some medical management. Open operations will need to be referred to specialist centres where the caseload will be sufficiently large for their skills to be retained. I think that these changes are inevitable, and surgeons will need to adapt to them by changing their training patterns and involving themselves much more in pharmacology and therapeutics. Perhaps one of the areas that will be free from a reduction in activity (and may in fact expand) is the transplantation of organs. It is likely that worn out organs will be replaced with greater ease and frequency either by organs produced from stem cells derived from the patient, or from animal organs after appropriate genetic manipulation aided by better immunosuppression. Surgeons involved in transplantation will need to be familiar with immunology and the control of the rejection process.
Endocrine and breast surgery Breast cancer is rapidly becoming a minimally invasive procedure, involving the excision of the lump alone, and it is likely that a cure for this condition will be discovered. Endocrine surgery seems fairly safe from attack, but again it is likely that better medical treatment will lead to a cure for thyrotoxicosis. The need to remove swellings from the thyroid to exclude cancer will diminish as the treatment for cancer becomes more specific. Also, parathyroid lesions will probably be removable by minimally invasive techniques. Orthopaedic surgery Orthopaedic surgery would, at first sight, seem to be immune from the changes seen in other specialties as the number of joint replacements and hip replacements increases almost geometrically. However, the possibility of finding more effective drug treatments for the degenerative diseases which currently require joint replacement is likely to increase, as will the use of cartilage cells to ‘line’ joints and produce new joint surfaces, which will almost certainly reduce the number of implants required. Sports injuries will increase if the general population becomes more active, thereby increasing the need to repair ligaments and muscles. Better methods of relieving pain may also make the need for orthopaedic surgery less necessary.
The future The time is coming for surgery in the UK to change its direction if it is to survive. Instead of specialist colleges in medicine and surgery, perhaps there should be one college for each disease grouping, for example, a cardiovascular college, a gastrointestinal college, a renal college, etc. These developments will need new and radical changes in the way surgeons work, and we should be thinking about them now. u
FURTHER READING Cremonesi A, Castriota F. Efficacy of a Nitanol filter device in the prevention of embolic events during carotid interventions. J Endovasc Ther 2002; 9(2): 155–9. Diethrich E B, Santiago O, Gustafson G, Heuser R R. Preliminary observations on the use of the Palmaz stent in the distal portion of the abdominal aorta. Am Heart J 1993; 125(2 Pt 1): 490–501. Dooley W C. The future of breast cancer screening and treatment. J Okla State Med Assoc 2002; 95(10): 635–8. Gutierrez de la Pena C, Marquez R, Fakih F et al. Simple closure or vagotomy and pyloroplasty for the treatment of a perforated duodenal ulcer; comparison of results. Dig Surg 2000; 17(3): 225–8. Henry M, Amor M, Masson I et al. Angioplasty and stenting of the extra cranial carotid arteries. J Endovasc Surg 1998; 5(4): 293–304.
Transplantation of organs and tissues Transplantation is one of the areas of surgery where activity will increase in the future. As organs ‘wear out’, they will be replaced, allowing individuals to live longer. The heart and kidneys in particular could be replaced by appropriately engineered porcine organs, but the liver will need to be replaced by human tissue, otherwise it will produce pig proteins. It may be possible in the long-term to grow organs from stem cells derived from the patient, thus eliminating the need for immunosuppression. Advances in immunosuppression have improved enormously, making it possible to transplant organs without rejection. Changes in surgical training The shift towards minimally invasive surgery, the increasing possibilities for drug therapy, and the change in disease patterns will mean that fewer surgeons will be required or, alternatively, they will need to change the way they work. There will also be implications for training. If fewer operations are performed (either open or laparoscopically), fewer centres will be required, which deal with a larger caseload of referrals from other centres. Hence, ‘super-specialists’, who perform fewer operations (see Black, Surgery 2003; 21(1): i–ii) will be needed; other surgeons will perform a smaller range of procedures such as laparoscopic interventions, patient investigations and medical management. Surgical training will need to change so that surgeons become members of disease-orientated groups of specialists (DOGS). In these groupings, surgeons will be able to carry out some operations (in which they will be trained), but not a whole range of operations. Within, for example, cardiovascular medicine, there will be doctors who deal with the cardiac issues, while others
SURGERY
The views expressed in this article reflect those of the author, and not necessarily those of the Surgery Editorial Board. If you wish to comment on the issues raised in this contribution, please write to: Arshad Makhdum Surgery Journal Medicine Publishing Company Limited 62 Stert Street Abingdon Oxon OX14 3UQ Or e-mail: [email protected]. The most thought-provoking and interesting letter will be published.
ii
© 2003 The Medicine Publishing Company Ltd
the future, and those that are performed will be by laparoscopic techniques, while the majority of patients will be treated by endovascular means.
What is the Future of Surgery in the UK?
Gastrointestinal disease Vagotomy, pyloroplasty and gastrectomy have virtually disappeared from the menu of operations performed today, except perhaps for the treatment of perforated duodenal ulcer. These procedures were among the most commonly performed in general surgery, and many surgeons learnt their trade carrying out these operations. It is probable that carcinoma of the gastrointestinal tract (which accounts for a good deal of the workload of gastrointestinal surgeons) will diminish, particularly if a cure for cancer or the improving efficiency of chemotherapy comes to fruition. A number of operations currently performed, for example, to avoid gastric reflux or to remove gall bladders, will also be under threat, if the cause of these conditions becomes apparent and drug therapy prevents their occurrence. Emergency surgery following trauma of the abdomen may be all that is left to occupy the gastrointestinal surgeon. Trauma will still occur and the ability to staff hospitals with an adequate number of surgeons who have enough elective duties while providing an emergency rota will be made more difficult.
Professor Sir Peter Bell
Surgery is an invasive form of treatment and must be a ‘last resort’. Research into conditions that can be treated by surgery aims to make it extinct, by discovering the basis for various disease processes and treating them medically. A prime example of this is peptic ulceration, which was the ‘bread and butter’ of surgical training in the UK in the 1970s and 1980s, but is now a condition that has almost vanished from the surgical lexicon with the discovery of Helicobacter pylori and its treatment by triple therapy and proton pump inhibitors. In the ‘molecular age’, there is a strong possibility that other areas of surgery (which currently keep many surgeons occupied) will also diminish in volume and importance. Further, it would be worth looking briefly at a number of different specialties within surgery and speculating where changes may occur in the future, perhaps making operations less necessary. In those areas where molecular advances have not (or will not) eradicate open surgery, there will be a definite tendency towards minimally invasive procedures, even though the introduction of such procedures is seldom evidence based.
Urological surgery The urologist already performs a lot of necessary work through a cystoscope. Open operations on the kidney are decreasing in frequency as stones are broken down by lithotripsy and laparoscopic renal procedures are performed more often. Drugs can shrink the prostate without the need for surgery, and prostate cancer (along with bladder cancer) is better understood. It is likely that if cures for these cancers are found, it will be less necessary for urological surgeons to operate at all.
Vascular surgery Vascular surgery has had a relatively short history, originating in the late 1950s and flourishing in the 1960s–80s. The advent of interventional activities (made possible by advances in technology) has meant that the number of operations for conditions such as aortic aneurysm and arterial bypass grafting has progressively diminished on a yearly basis, as interventional procedures have increased. Recently, the frequently performed operation of carotid endarterectomy (which is supported by randomized studies) has come under threat from carotid angioplasty, which seems to work quite well, particularly if a protective device to prevent embolization is used. At present, use of this technique is not evidence based, but if it is successful, will mean the demise of carotid surgery in the long-term. Although there is little evidence that such procedures are better than open operations, patients prefer them because of the relative lack of trauma. Because of these changes, the number of open vascular procedures has diminished progressively in recent years. Also, the reduction in smoking and the emergence of statins and allied drugs may mean that the disease process (atheroma) is becoming less common. It is likely that fewer open vascular operations will be necessary in
Cardiopulmonary surgery If cancer is controlled and smoking diminishes, the need for lung surgery will lessen considerably. The requirement to perform coronary artery bypass grafting is diminishing already, as balloon dilatation and the ability to insert stents increases. The invention of drug-coated stents (which have been shown to reduce intimal hyperplasia and restenosis) will make further inroads in the need to perform open surgery. The remaining operations will be performed by minimally invasive techniques and operations on the beating heart will become more common and carried out in fewer centres. Even heart transplantation is at risk, with progress being made towards the injection of stem cells into the myocardium, which then differentiate into functional heart muscle, thereby improving cardiac activity. Congenital valve problems will probably still continue, although they will be less in number because of improved antepartum screening. Ear, nose and throat (ENT) and maxillofacial surgery The improvement in medical treatment and a better understanding of the underlying disease processes which ENT and maxillofacial surgeons encounter will lead to a reduction in activity in these areas. Reconstructive surgery for excision of cancers will also diminish if a cure for cancer is found or chemotherapy improves. Problems will still occur, but the maxillofacial and ENT surgeons may well be left with trauma as their main source
Peter R F Bell is the Foundation Professor of Surgery at Leicester University, Leicester, UK. He qualified from Sheffield University and trained in surgery in Sheffield, Glasgow, UK, and Denver, USA. His interests are vascular surgery and transplantation.
SURGERY
i
© 2003 The Medicine Publishing Company Ltd
LEADING ARTICLE
of operative activity and, as in other specialties, many fewer surgeons will be required.
will deal with the peripheral, arterial or venous system, some performing interventional procedures and some medical management. Open operations will need to be referred to specialist centres where the caseload will be sufficiently large for their skills to be retained. I think that these changes are inevitable, and surgeons will need to adapt to them by changing their training patterns and involving themselves much more in pharmacology and therapeutics. Perhaps one of the areas that will be free from a reduction in activity (and may in fact expand) is the transplantation of organs. It is likely that worn out organs will be replaced with greater ease and frequency either by organs produced from stem cells derived from the patient, or from animal organs after appropriate genetic manipulation aided by better immunosuppression. Surgeons involved in transplantation will need to be familiar with immunology and the control of the rejection process.
Endocrine and breast surgery Breast cancer is rapidly becoming a minimally invasive procedure, involving the excision of the lump alone, and it is likely that a cure for this condition will be discovered. Endocrine surgery seems fairly safe from attack, but again it is likely that better medical treatment will lead to a cure for thyrotoxicosis. The need to remove swellings from the thyroid to exclude cancer will diminish as the treatment for cancer becomes more specific. Also, parathyroid lesions will probably be removable by minimally invasive techniques. Orthopaedic surgery Orthopaedic surgery would, at first sight, seem to be immune from the changes seen in other specialties as the number of joint replacements and hip replacements increases almost geometrically. However, the possibility of finding more effective drug treatments for the degenerative diseases which currently require joint replacement is likely to increase, as will the use of cartilage cells to ‘line’ joints and produce new joint surfaces, which will almost certainly reduce the number of implants required. Sports injuries will increase if the general population becomes more active, thereby increasing the need to repair ligaments and muscles. Better methods of relieving pain may also make the need for orthopaedic surgery less necessary.
The future The time is coming for surgery in the UK to change its direction if it is to survive. Instead of specialist colleges in medicine and surgery, perhaps there should be one college for each disease grouping, for example, a cardiovascular college, a gastrointestinal college, a renal college, etc. These developments will need new and radical changes in the way surgeons work, and we should be thinking about them now. u
FURTHER READING Cremonesi A, Castriota F. Efficacy of a Nitanol filter device in the prevention of embolic events during carotid interventions. J Endovasc Ther 2002; 9(2): 155–9. Diethrich E B, Santiago O, Gustafson G, Heuser R R. Preliminary observations on the use of the Palmaz stent in the distal portion of the abdominal aorta. Am Heart J 1993; 125(2 Pt 1): 490–501. Dooley W C. The future of breast cancer screening and treatment. J Okla State Med Assoc 2002; 95(10): 635–8. Gutierrez de la Pena C, Marquez R, Fakih F et al. Simple closure or vagotomy and pyloroplasty for the treatment of a perforated duodenal ulcer; comparison of results. Dig Surg 2000; 17(3): 225–8. Henry M, Amor M, Masson I et al. Angioplasty and stenting of the extra cranial carotid arteries. J Endovasc Surg 1998; 5(4): 293–304.
Transplantation of organs and tissues Transplantation is one of the areas of surgery where activity will increase in the future. As organs ‘wear out’, they will be replaced, allowing individuals to live longer. The heart and kidneys in particular could be replaced by appropriately engineered porcine organs, but the liver will need to be replaced by human tissue, otherwise it will produce pig proteins. It may be possible in the long-term to grow organs from stem cells derived from the patient, thus eliminating the need for immunosuppression. Advances in immunosuppression have improved enormously, making it possible to transplant organs without rejection. Changes in surgical training The shift towards minimally invasive surgery, the increasing possibilities for drug therapy, and the change in disease patterns will mean that fewer surgeons will be required or, alternatively, they will need to change the way they work. There will also be implications for training. If fewer operations are performed (either open or laparoscopically), fewer centres will be required, which deal with a larger caseload of referrals from other centres. Hence, ‘super-specialists’, who perform fewer operations (see Black, Surgery 2003; 21(1): i–ii) will be needed; other surgeons will perform a smaller range of procedures such as laparoscopic interventions, patient investigations and medical management. Surgical training will need to change so that surgeons become members of disease-orientated groups of specialists (DOGS). In these groupings, surgeons will be able to carry out some operations (in which they will be trained), but not a whole range of operations. Within, for example, cardiovascular medicine, there will be doctors who deal with the cardiac issues, while others
SURGERY
The views expressed in this article reflect those of the author, and not necessarily those of the Surgery Editorial Board. If you wish to comment on the issues raised in this contribution, please write to: Arshad Makhdum Surgery Journal Medicine Publishing Company Limited 62 Stert Street Abingdon Oxon OX14 3UQ Or e-mail: [email protected]. The most thought-provoking and interesting letter will be published.
ii
© 2003 The Medicine Publishing Company Ltd