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The honor and pride I felt when first invited to write the foreword to this textbook is tempered only by my feelings of profound sorrow and loss for the editor and creator, my dear friend and colleague, David J. Sugarbaker. When David passed in August of 2018, he had just turned 65 years old, far too young for such a monumental and energetic force in thoracic surgery to leave his profession. Larger than life, he was one of the most prominent surgeons in our field. Enter his name in any web browser and you will encounter superlatives such as outstanding, iconic, greatest, master, mentor, role model, pioneer, innovator and scientist. His prescription for life was embodied in the phrase “clarity of purpose and focused attention,” the leitmotif of his career.

As the son of a surgeon, David was raised in a family of doctors. His father trained at the Memorial Hospital in New York City. Strongly influenced by the work of James Ewing, he became a busy and well-respected oncologic surgeon. After his training, he established a private surgical practice in the Ozark Mountains in Missouri. David’s mother was a nurse. His two elder brothers became surgeons and his sister a pediatrician. From a very early age, David knew he wanted to be a surgeon.

When David was in high school, he spent much of his spare time with his father in the operating room at the hospital. At home, he also took care of the Wistar rats in his father’s garage laboratory, investigating why cancer cells migrate from one organ to another. Was it simply a mechanical phenomenon or a seed and soil attraction?

The Sugarbaker family lived on an apple orchard, where David worked as he was growing up. Charged with the responsibility of caring for the orchard, which included operating heavy farm equipment, he derived a strong sense of pride and responsibility for his work, which carried him throughout his career, and he learned first-hand of the value of perseverance and dedication.

Like his father and older siblings, he attended Cornell University Medical College, graduating at the top of his class, a member of the Alpha Omega Alpha Society. Then, following in the footsteps of his older brother, Paul, he successfully matched with the Peter Bent Brigham residency program in surgery. During his training years, he was a research fellow in the laboratory of Dr. Raj Goyal, a prominent esophageal physiologist. Further influenced by the clinical works of Mr. Ronald Belsey and Dr. E. Griffith Pearson, he became fascinated with the esophagus.

With support and encouragement from his chief mentor at the Brigham, Dr. John Mannick, a vascular surgeon and chief of the surgical service, he obtained a coveted slot in the thoracic surgery training program at the University of Toronto under the leadership of the father of modern thoracic surgery, F. Griffith Pearson, and the legendary pioneer of lung transplantation, Joel D. Cooper. While there, he also worked with and established a lifelong friendship with Alec Patterson. Collectively, this foursome represented a powerhouse of talent. All four surgeons—Pearson, Cooper, Patterson and Sugarbaker—became Presidents of the American Association for Thoracic Surgery (AATS).

When David returned to Boston after his fellowship, John Mannick had the vision, foresight, and temerity to allow him to establish the first Division of General Thoracic Surgery in the United States. Under David’s leadership, the division became the first training track specific to thoracic surgery in the country.

At Brigham and Women’s Hospital, David used his talents and creativity to become a consummate master thoracic surgeon-scientist, innovator, teacher and mentor—a force of nature. He did this with amazing vision and boundless energy, mapping out his objectives, always aiming for the highest level of achievement.

He had a great belief and confidence in himself, accompanied by a strong sense of purpose. He made it a point to know exactly what he was doing at all times. He described this to me as being in the moment, as having clarity of purpose and focused attention—the “essence of excellence” (the title of his AATS presidential address)—and he encouraged this sensibility in all of his trainees.

He nurtured a sense of confidence and purpose in his patients, too, espousing a philosophy of “quality life extension leading to cure.” His ability to understand his purpose and focus his efforts on the task at hand truly defines the essence of excellence in a surgeon.

His achievements were many but foremost among them were the advances he made in the treatment of mesothelioma. He pioneered the highly effective tri-modality approach to treating early-stage peritoneal mesothelioma, and he introduced the concept of heated intraoperative chemotherapy in order to obtain maximal cytoreduction. He conducted the early pleural mesothelioma studies that identified markers that would allow for earlier diagnosis and refine staging. He helped identify subtypes of mesothelioma, which led to improved individualized treatment plans. He supported and catalyzed translational research that was essential to establishing the genomics of mesothelioma.

He developed a world-class cancer treatment program at Brigham and Women’s Hospital and later at St. Luke’s Hospital at Baylor College of Medicine in Houston, Texas.

He performed the first lung transplant in Massachusetts and the first double lung transplant in New England, and from the very beginning adopted and pioneered new developments in minimally invasive surgery now better known as video-assisted thoracic surgery (VATS). Other contributions to thoracic surgery included his work as the chair of the surgery committee for the Cancer and Leukemia Group B (CALGB), which advocated multimodality care in lung cancer and later esophageal cancer. He had the foresight to establish a tumor bank at the very beginning of his career, one of the first in the United States.

Every Wednesday morning at 6:30 A.M., he carved out a special time for his fellows and residents, who would meet with him in his office for what he called “fireside chats.” An admirer of Winston Churchill, a portrait of the famed English prime minister hung on the wall in his office. Here he would probe his trainees’ aspirations and ambitions. He would discuss their future plans and give advice on practical things like how to start up a practice and how to work within a division to build a team. He challenged them to do their best to reach for excellence for their patients and the discipline. He counseled them on the value of humor and hope when meeting with families and patients, and, of course, he instilled in them the importance of clarity of purpose and focused attention. In his lifetime, he trained dozens of fellows and residents in thoracic surgery. An astonishing 22 of his trainees became chairs of thoracic surgery divisions or departments in the United States and abroad.

My first encounter with Dr. Sugarbaker dates back to the early 1990s. We were both thrilled by the rise of new developments in VATS, and we met on several occasions during meetings in the United States and Europe. I invited him over to my hospital in Leuven, Belgium, where he was accompanied by his wife, Linda. My wife and I grew to know Linda as David’s best friend, emotional rock, and soulmate. Together they raised six children, and although Linda took most of the daily responsibility and despite his professional responsibilities, David relished his role as husband and father and always made time for each of his children. He spent much of his spare time watching his children play soccer or baseball, organizing the outdoor barbecue on Memorial Day, or taking them to Lexington for the Reenactment (of the Battle of Lexington).

David was very proud of his Dutch roots, and on several occasions we discussed Dutch culture and politics. When we would get together, I would teach him and Linda a few Dutch words or little nursery rhymes to his great enjoyment.

In 2014 he took on a new challenge as the Director of the Lung Institute at Baylor College of Medicine and St. Luke’s Medical Center in Houston, Texas. After my retirement as Chief of the Department of Thoracic Surgery at Leeuven Hospital, Dr. Sugarbaker invited me to be the Sally and Michael Gordon visiting scholar in the Division of Thoracic Surgery at Brigham and Women’s Hospital and Harvard Medical School. I availed myself of this incredible opportunity between 2011 and 2014, and subsequently at Baylor between 2015 and 2017.

Adult Chest Surgery, now rightfully named Sugarbaker’s Adult Chest Surgery, is the embodiment of David’s legacy. The coeditors of this third edition—Raphael Bueno, Bryan M. Burt, Shawn S. Groth, Gabriel Loor, and Andrea S. Wolf—have ably stepped in to fill the void created by David’s passing. Not surprisingly, the textbook received high accolades for the first two editions and is considered a must-have thoracic surgery textbook across the globe.

Dr. Sugarbaker had a tradition of presenting a replica of the famous Boston handcrafted Chelsea Ship’s Bell Clock to his fellows and residents at the end of their training. Once an essential instrument of navigation, it is a metaphor for the many surgeons David personally trained. Each quarter-hour, the bell rings, as it does in the homes of his many former residents, not the least in my home, a constant reminder of the great and loyal teacher and dear friend David Sugarbaker was.

Toni Lerut

Emeritus Professor of Surgery

University of Leuven

Emeritus Chairman, Department of Thoracic Surgery, University Hospital

Leuven, Belgium

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