From the Guidelines
A thoracic surgeon who is cardiothoracic surgery boarded but not general surgery boarded may face limitations in performing complex thoracic operations that require extensive abdominal surgical expertise, such as esophagectomies with abdominal components, transhiatal esophagectomies, and esophageal reconstructions requiring gastric pull-up or colon interposition. These limitations arise because cardiothoracic training traditionally focuses more on cardiac procedures and thoracic operations above the diaphragm, while general surgery training provides comprehensive experience with abdominal anatomy and techniques 1.
Some of the specific procedures that may be challenging for a cardiothoracic surgery boarded thoracic surgeon without general surgery training include:
- Complex diaphragmatic hernia repairs
- Combined thoracoabdominal resections for tumors at the gastroesophageal junction
- Surgeries requiring extensive abdominal dissection, management of abdominal viscera, or familiarity with abdominal vascular structures
However, it's essential to note that the actual limitations vary widely based on the surgeon's specific training pathway, fellowship experience, and institutional credentialing requirements, as many cardiothoracic surgery programs now incorporate relevant abdominal surgical training for thoracic surgeons 1. The evidence suggests that thoracic surgeons have improved perioperative surgical outcomes and better long-term survival in patients with cancer when they are treated by specialists in cancer surgery and at higher-volume centers 1. Additionally, studies have consistently noted better long-term survival after surgery performed by a thoracic or cardiac surgeon vs a general surgeon, with a pooled OR for perioperative mortality of 0.78 (95% CI, 0.7-0.88; P,.0001) for thoracic surgeons vs general surgeons 1.
In terms of morbidity, mortality, and quality of life, the most critical factor is the surgeon's expertise and volume of procedures, rather than their specific board certification. Therefore, a cardiothoracic surgery boarded thoracic surgeon without general surgery training may still be able to perform complex thoracic operations safely and effectively, as long as they have received adequate training and have sufficient experience in these procedures 1.
From the Research
Typical Thoracic Surgery Operations
The following are typical thoracic surgery operations that a thoracic surgeon potentially may not be able to perform if they were not general surgery boarded, but were cardiothoracic surgery boarded:
- Esophagectomy for benign diseases, such as esophageal perforation or achalasia, which may require general surgery techniques 2
- Gastric or intestinal surgery for conditions such as gastroesophageal reflux disease or intestinal obstruction, which are typically managed by general surgeons
- Hernia repair, such as hiatal hernia repair, which may require general surgery techniques
- Surgery for benign lung diseases, such as lung abscess or empyema, which may require general surgery techniques
Limitations of Cardiothoracic Surgery Boarding
Cardiothoracic surgery boarding may not provide the same level of training in general surgery techniques as general surgery boarding. According to 3, cardiothoracic surgeons provide care to patients with a range of disorders of the heart, lungs, esophagus, and major blood vessels of the chest, but may not have the same level of expertise in general surgery techniques. Additionally, 4 notes that thoracic surgery certification is dynamic and evolving, but may not necessarily include general surgery techniques.
Specific Procedures
Some specific procedures that a thoracic surgeon may not be able to perform without general surgery boarding include:
- Minimally invasive esophagectomy for benign diseases, such as esophageal perforation or achalasia 2
- Gastric or intestinal surgery for conditions such as gastroesophageal reflux disease or intestinal obstruction
- Hernia repair, such as hiatal hernia repair
- Surgery for benign lung diseases, such as lung abscess or empyema
Certification and Training
The American Board of Thoracic Surgery (ABTS) offers certification in thoracic surgery, but may not provide the same level of training in general surgery techniques as general surgery boarding 5, 6. The ABTS also offers subspecialty certification in congenital heart surgery, which requires additional training and expertise 6.