Sharing the Airway: The Importance of Good Communication Between Anesthesiologist and Surgeon.

One of the most challenging tasks during airway surgery is ensuring adequate ventilation throughout the procedure. Because the airway is shared between surgeon and anesthesiologist, successful oxygenation and ventilation of the patient can only be accomplished through close collaboration during the various stages of the procedure. This includes periods in which surgical airway manipulation compromises adequate ventilation and periods in which ventilation interferes with the surgical environment. With continuous communication between surgeon and anesthesiologist, optimal outcomes can be achieved.

Carinal Pneumonectomy.

Carcinoma of the lung can involve the carina. Resection then encompasses resection of the lung with the carina. Success of this complex procedure is based on careful selection of patients, judicious use of multimodality therapies, and expert multidisciplinary care. Selection of patients is based on staging of the cancer and an evaluation of their cardiopulmonary reserve. The surgery must aim at removing all of the malignancy and nodes. The anastomosis must be tension free and buttressed with a vascularized pedicled flap. Multiple ways are available to maintain proper ventilation of patients during the reconstruction of the carina.

Experiences with Prosthetic Airway Replacement.

Prosthetic airway reconstruction is seldom indicated in modern airway surgery because more than one-half the trachea can now be safely resected and the trachea be primarily reconstructed. In addition, an ideal prosthesis has yet to be developed with the use of those currently available being often associated with major morbidities and poor long-term outcomes. Recent developments in tracheal transplantation or tissue engineering strategies that promote and accelerate epithelial repair by controlling cell organization remains experimental, but showing great promise.

Recognition and Management of Life-Threatening Tracheovascular Fistulae and How to Prevent Them.

Formation of a fistula between trachea and a major artery or vein in the root of the neck threatens life quickly from combination of major external bleeding and hemorrhagic shock, and asphyxiation from flooding of the proximal airways with blood. This complication can occur after cervical tracheostomy open or percutaneous, tracheal resection, cervical exentration and anterior mediastinal tracheostomy, and laryngectomy. The recognition of its occurrence is clinical based on a high index of clinical suspicion. The life-saving operation for this complication carries potential risk for ischemic stroke. Impairment of arterial perfusion to the right arm and ischemia is another potential complication.

Importance of a Team Effort in Success of Airway Surgery.

The thoracic surgeon occupies a unique position in the team of those who are involved in looking after surgical patients in need of airway operations. It may be for urgent and life-threatening situations as in tracheo-vascular fistula or critical airway obstruction. Or it may be semiurgent in the intensive care unit in patients on assisted ventilation requiring tracheostomy (open or percutaneous). It may be elective for patients with tracheal stricture (benign or malignant), cervical exenteration, anterior mediastinal tracheostomy, and tracheo-bronchomalacia.

Birth of Airway Surgery and Evolution over the Past Fifty Years.

Significant developments in airway surgery occurred following the introduction of mechanical ventilators and intubation with cuffed endotracheal tubes during the poliomyelitis epidemic of the 1950s. The resulting plethora of postintubation injuries provided extensive experience with resection and reconstruction of stenotic tracheal lesions. In the early 1960s, it was thought that no more 2 cm of trachea could be removed. By the late 1960s, this was challenged owing to better knowledge of airway anatomy and blood supply, tension-releasing maneuvers, and improved anesthetic techniques. Currently, about half of the tracheal length can be safely removed and continuity restored by primary anastomosis.

Tuberculosis and Other Granulomatous Diseases of the Airway.

Granulomatous diseases of the airway are challenging lesions to diagnose and effectively manage not only because they are uncommon but also because they can occur in different forms, each with unique clinical and radiological characteristics. Most such lesions can be effectively managed conservatively with repeated airway dilatation, use of intraluminal stents, and specific antimicrobial treatment. The only exception is those lesions presenting with localized airway obstruction wherein surgical resection may be indicated and beneficial.

Video-assisted and minimally-invasive open chest surgery for the treatment of mediastinal tumors and masses.

This article reviews the anatomy of the mediastinum as well as indications, limitations, techniques, and results of video-assisted thoracic surgery (VATS) and other minimally-invasive open-chest surgery approaches currently used for the surgical management of mediastinal tumors and masses. It is written by two surgeons with vastly different backgrounds and thoracic surgical experience. One of them is young and very familiar with VATS approaches and technologies while the other is a senior surgeon relatively unfamiliar with minimally-invasive techniques. This combination of authorship is ideal to analyze the pros and cons of the use of minimally-invasive approaches for the surgical management of mediastinal lesions such as thymic epithelial tumors (TETs) or neurogenic tumors. This is important because several thoracic surgeons have expressed concerns about the ability of thoracoscopic procedures to maintain adherence to sound oncological principles.

Surgical anatomy of the tracheobronchial tree.

Airway surgery is often indicated in the management of benign or malignant pathological processes of the tracheobronchial tree. The surgeon undertaking this type of work has, however, the responsibility of understanding the particular anatomy applicable to these structures and procedures as well as be able to correlate imaging, intraoperative findings and anatomy. These are important considerations if one wants to reduce operative morbidity and improve potential for better long-term results. This paper reviews the most important anatomic features of the tracheobronchial tree putting emphasis on those features that are important to surgeons performing surgical procedures on those organs.

Evolution of thoracic surgery in Canada.

BACKGROUND: Canada's contributions toward the 21st century's practice of thoracic surgery have been both unique and multilayered. Scattered throughout are tales of pioneers where none had gone before, where opportunities were greeted by creativity and where iconic figures followed one another. OBJECTIVE: To describe the numerous and important achievements of Canadian thoracic surgeons in the areas of surgery for pulmonary tuberculosis, thoracic oncology, airway surgery and lung transplantation. METHOD: Information was collected through reading of the numerous publications written by Canadian thoracic surgeons over the past 100 years, interviews with interested people from all thoracic surgery divisions across Canada and review of pertinent material form the archives of several Canadian hospitals and universities. RESULTS: Many of the developments occurred by chance. It was the early and specific focus on thoracic surgery, to the exclusion of cardiac and general surgery, that distinguishes the Canadian experience, a model that is now emerging everywhere. From lung transplantation in chimera twin calves to ex vivo organ preservation, from the removal of airways to tissue regeneration, and from intensive care research to complex science, Canadians have excelled in their commitment to research. Over the years, the influence of Canadian thoracic surgery on international practice has been significant. CONCLUSIONS: Canada spearheaded the development of thoracic surgery over the past 100 years to a greater degree than any other country. From research to education, from national infrastructures to the regionalization of local practices, it happened in Canada.

[Intervenir auprès des hommes training in the Montérégie health network. An organizational perspective]. / La formation Intervenir auprès des hommes dans le réseau de santé en Montérégie. Une perspective organisationnelle.

INTRODUCTION: The primary objective of the For'hommes project deployed since 2011 in the Montérégie region (south of Montreal in Quebec) is to increase awareness and train Health and Social Services Centers (CSSS) administrators, clinical supervisors and intervention workers in dealing with the male clientele. OBJECTIVE: An evaluation of project implementation allowed documentation of the organizational practices enabling the development of the "lntervenir auprès des hommes" training in the CSSS. METHOD: Eight interviews with administrators and supervisors from five of the seven CSSS were conducted in 2013. RESULTS: The awareness and training programmes prompted the CSSSs to assess the services offered and review certain practices (organizational or clinical) targeting male clienteles. The welcoming process, analysis of the requests and intervention with men are now more adapted to their realities and needs: more rapid intervention, phone support prior to management, helping men with referrals to community social services, a better understanding of the calls for help. To pursue the deployment of services adapted to a male clientele, administrators and supervisors emphasized the importance of continuing to offer training to CSSS intervention workers. CONCLUSION: Reflection emerging from the training of the managers and supervisors represents a promising approach, as it involves the key actors in the organization's. We can therefore consider "lntervenir auprès des hommes" training to be a key element of improvement of the services offered by CSSSs.

"Escola em sofrimento": pesquisa-ação sobre situações de trabalho de risco para a saúde mental em meio escolar / "L'école en souffrance": recherche-action sur les situations de travail à risque pour la santé mentale en milieu scolaire / "School in distress": action research on risky work situations with regards to mental health in school settings

Esta pesquisa-ação, realizada em duas escolas de ensino médio no Quebec, foi baseada numa intervenção em psicodinâmica do trabalho, com professores, profissionais da educação, pessoal de apoio e diretoria. O objetivo foi analisar o sofrimento e as estratégias defensivas individuais e coletivas, além de identificar situações de risco para a saúde mental no trabalho. O segundo aspecto desta pesquisa visava o acompanhamento, no ambiente escolar, com a tomada de consciência dos efeitos deletérios da organização do trabalho e da necessidade de agir através de prevenção primária (na fonte) em prol da saúde e da segurança do trabalho...

Cette recherche-action conduite dans deux écoles de niveau secondaire au Québec (lycées), s'est appuyée sur une enquête de psychodynamique du travail réalisée avec des enseignants, des professionnels de l'éducation, des membres du personnel de soutien et de direction. L'objectif était d'analyser la souffrance et les stratégies défensives individuelles et collectives puis d'identifier des situations à risque pour la santé mentale au travail. Un deuxième volet visait l'accompagnement du milieu scolaire dans une prise de conscience des effets délétères de l'organisation du travail et la nécessité d'agir en prévention primaire (à la source), pour la santé et sécurité du travail...

This paper relies on an action research conducted in a perspective of health and security at work in two high schools (secondary level) in Quebec. The objective was to identify work situations with risks for the mental health of the staff, by the analysis of the suffering at work and the individual and collective defensive strategies tied to the work organization. More specifically, the study aimed at accompanying the participants (teachers, education professionals, support staff and assistant principals) in the development of an action plan to prevent problems of mental health at work...