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BRIEF HISTORY OF GENERAL THORACIC SURGERY Chest surgery has come a long way from a single costal extraction to populate the earth to a procedure that resembles a video game. Thoracic surgery has been known since ancient times, however it was not until the past century that general thoracic surgery has become a separate surgical subspecialty. As this field of surgery has evolved, so has our knowledge of diseases we treat inside the chest. 1 At the beginning of the 20th century, the field of general surgery began expanding in response to the need for expertise in different areas of surgery. During the first half of the 20th century tuberculosis was the pathology most significant to the general thoracic surgeon. With this epidemic, along with World War I-related chest injuries, a special need for surgeons knowledgeable in thoracic diseases arose. Because of this need, general surgeons would begin dedicating their practice to thoracic pathologies. 2,3 In 1909 Jacobaeus performed his famous thoracoscopy, this first important period in thoracic surgery was known as the era of enthusiasm. By 1914 tuberculosis was a worldwide pandemic and for some time it became the number one cause of death in Colombia. War and tuberculosis were the 2 main factors pivoting general thoracic from general surgery, although it was not foreign war but domestic armed conflict that required the Colombian general surgeon to start focusing on chest injuries. In 1914, Dr Pompilio Mart ınez performed the country's first cardiac suture because of a penetrating chest injury in Bogota. To answer to this new era of thoracic warfare injuries and tuberculosis, the American Association for Thoracic Surgery was created in 1917. 4-6 It is worth mentioning that the first surgery ever filmed was a general thoracic procedure by Dr Alejandro Posada in 1899 in Argentina. Because cardiovascular disease was not a major issue at this time, the need for 2 separate thoracic subspecialties was not necessary, and thus North America and Europe

Introduction Despite being one of the main vacation destinations in the world, health care in the Caribbean faces many difficulties. The challenges involved in these islands’ medical care range from low-resource institutions to lack of specialized care. In the field of thoracic and cardiac surgery, many limitations exist, and these include the lack of access to cardiac surgery for many small islands and little governmental funding for minimally invasive approaches in thoracic surgery. Methods Literature review was done using PubMed/MEDLINE and Google Scholar databases to identify articles describing the characteristics of thoracic and cardiac surgery departments on Caribbean islands. Articles on the history, current states of practice, and advances in cardiothoracic surgery in the Caribbean were reviewed. Results Regardless of the middle to high-income profile of the Caribbean, there are significant differences in the speed of technological growth in cardiothoracic surgery from island to island, as well as disparities between the quality of care and resources. Many islands struggle to advance the field of cardiothoracic surgery both through lack of local cardiac surgery centers and limited financial funding for minimally invasive thoracic surgery. Conclusions Cardiac and thoracic surgery in the Caribbean depend not only on the support from local government policies and proper distribution of healthcare budgets, but efforts by the surgeons themselves to change and improve institutional cultures. Although resource availability still remains a challenge, the Caribbean remains an important region that deserves special attention with regard to the unmet needs for long-term sustainability of chest surgery.

In developing countries, limited resources and low health budgets result in slow developments in the field of cardiac surgery. As a consequence, advances in surgery become a challenging process. In Colombia, most institutions do not have the capacity or infrastructure for minimally invasive and video-assisted cardiac surgery, let alone robotic assisted cardiac surgery (RACS). Despite the challenges, efforts to overcome these hurdles are critical for the future of cardiac surgery in low-income settings. Here we describe the first cases of robotic cardiac surgeries performed in Colombia.

BackgroundThe combined treatment of beta-blockers with ablation and Implanted cardioverter defibrillation therapy, continues to be the mainstay treatment for ventricular arrhythmias (VAs). Despite treatment, some patients remain refractory.  Recent studies have shown success rates using video-assisted thoracoscopic (VATS) cardiac denervation as an effective therapeutic option for these patients.Case series presentationDuring a period of three years, from 2015 through 2017, twenty patients (N = 20) failed traditional medical and interventional treatment for the management of ventricular arrhythmias and electrical storms. After remaining refractory, the patients were referred to our thoracic surgery department for a VATS based treatment. The patients all had ventricular arrhythmias and electrical storms secondary to different cardiomyopathies. The patients were refractory to combined medical (beta-blockers), Implanted Cardioverter defibrillation (ICD) and ablation therapy. All twenty patients agreed to surgery and were taken to cardiac denervation using a bilateral VATS approach by two thoracic surgeons at a single Cardiothoracic center. During the month prior to bilateral VATS denervation a combined total of twenty-nine (N = 29) ICD shocks were registered in addition to six (N = 6) cases of electrical storms averaging three (N = 3) shocks per day. Mean shocks per patient was 2.3. During the first three months following VATS, the patients had a 90% (N = 18/20) total resolution of ICD registered shocks, a 100% (N = 6/6) resolution of electrical storms, and a 92% (N = 11/12) resolution of shocks in patients having previous ablation therapy. No complications were documented following surgery except for one case of pneumothorax as a result of the procedure, and there were no peri-operative mortalities.ConclusionsBilateral thoracoscopic cardiac denervation can be a safe and seemingly effective therapeutic option for patients presenting with life-threatening refractory ventricular arrhythmias and electrical storms in a variety of cardiomyopathies including Chagas disease.

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