Preoperative computed tomography-guided microcoil localization of small peripheral pulmonary nodules: a prospective randomized controlled trial.

OBJECTIVES: Growing, small, peripheral, pulmonary nodules in patients at high risk for lung cancer lead to requests for video-assisted thoracoscopic (VATS) resection for pathologic diagnosis. The purpose of this randomized controlled trial was to determine if preoperative localization using percutaneously placed computed tomography (CT)-guided platinum microcoils decreases the need for thoracotomy or VATS anatomic resection (segmentectomy/lobectomy) for diagnosis. METHODS: Patients with undiagnosed nodules of 15 mm or less were randomized to either no localization or preoperative microcoil localization. Coils were placed with the distal end deep to the nodule and the superficial end coiled on the visceral pleural surface with subsequent visualization by intraoperative fluoroscopy and VATS. Nodules were removed by VATS wedge excision using endostaplers. The primary outcome was a VATS wedge excision for pathologic diagnosis of the nodule without the need for either thoracotomy or VATS anatomic resection. RESULTS: Sixty patients were randomized and 56 underwent surgery between March 2010 and June 2012. Twenty-nine underwent microcoil localization and 27 did not. The baseline characteristics (age, sex, forced expiratory volume in the first second of expiration, nodule size/depth) were similar. The coil group had a higher rate of successful diagnosis with VATS wedge resection alone (27/29 vs 13/27; P < .001), decreased operative time to nodule excision (37 ± 39 vs 100 ± 67 minutes; P < .001), and reduced stapler firings (3.7 ± 2.0 vs 5.9 ± 31; P = .003) with no difference in total costs. Pathologic diagnoses included 14 benign nodules, 32 primary lung malignancies, and 10 metastases. There were no clinically significant complications related to the coil placement or wedge resection. CONCLUSIONS: Preoperative CT-guided microcoil localization decreases the need for thoracotomy or VATS anatomic resection for the diagnosis of small peripheral pulmonary nodules.

A brief tool to assess capacity to consent for medical care among homeless individuals with problematic substance use: study protocol.

BACKGROUND: Public health care increasingly uses outreach models to engage individuals who are marginalized, many of whom misuse substances. Problematic substance use, together with marginalization from the health care system, among homeless adults makes it difficult to assess their capacity to consent to medical care. Tools have been developed to assess capacity to consent; however, these tools are lengthy and unsuitable for outreach settings. The primary objective of this study is to develop, validate, and pilot a brief but sensitive screening instrument which can be used to guide clinicians in assessing capacity to consent in outreach settings. The goal of this paper is to outline the protocol for the development of such a tool. METHODS/DESIGN: A brief assessment tool will be developed and compared to the MacArthur Competency Assessment Tool for Treatment (MacCAT-T). As list of 36 possible questions will be created by using qualitative data from clinician interviews, as well as concepts from the literature. This list will be rated by content experts according to the extent that it corresponds to the test objectives. The instrument will be validated with 300 homeless adult volunteers who self-report problematic substance use. Participants will be assessed for capacity using the MacCAT-T and the new instrument. A combination of Classical Test Theory and advanced psychometric methods will be used for the psychometric analysis. Corrected Item-Total correlation will be examined to identify items that discriminate poorly. Guided exploratory factor analysis will be conducted on the final selection of items to confirm the assumptions for a unidimensional polytomous Rasch model. If unidimensionality is confirmed, an unstandardized Cronbach Alpha will be calculated. If multi-dimensionality is detected, a multidimensional Rasch analysis will be conducted. Results from the new instrument will be compared to the total score from the MacCAT-T by using Pearson's correlation test. The new instrument will then be piloted in real-time by street outreach clinicians to determine the acceptability and usefulness of the new instrument. DISCUSSION: This research will build on the existing knowledge about assessing capacity to consent and will contribute new knowledge about assessing individuals whose judgment is impaired by substance use.

The use of thoracoscopy to enhance medical students' interest and understanding of thoracic anatomy.

AIM: To develop a video-based educational tool designed for teaching thoracic anatomy and to examine whether this tool would increase students' stimulation and motivation for learning anatomy. METHODS: Our video-based tool was developed by recording different thoracoscopic procedures focusing on intraoperative live thoracic anatomy. The tool was then integrated into a pre-existing program for first year medical students (n = 150), and included cadaver dissection of the thorax and review of clinical problem scenarios of the respiratory system. Students were guided through a viewing of the videotape that demonstrated live anatomy of the thorax (15 minutes) and then asked to complete a 5-point Likert-type questionnaire assessing the video's usefulness. Apart from this, a small group of entirely different set of students was divided into two groups, one group to view the 15-minute video presentation of thoracoscopy and chest anatomy and the other group to attend a 15-minute lecture of chest anatomy using radiological images. Both groups took a 10-item pretest and post-test multiple choice questions examination to assess short-term knowledge gained. RESULTS: Of 150 medical students, 119 completed the questionnaires, 88.6% were satisfied with the thoracoscopic video as a teaching tool, 86.4% were satisfied with the quality of the images, 69.2% perceived it to be beneficial in learning anatomy, 96.2% increased their interest in learning anatomy, and 88.5% wanted this new teaching tool to be implemented to the curriculum. Majority (80.7%) of the students increased their interest in surgery as a future career. Post-test scores were significantly higher in the thoracoscopy group (P = 0.0175). CONCLUSION: Incorporating live surgery using thoracoscopic video presentation in the gross anatomy teaching curriculum had high acceptance and satisfaction scores from first year medical students. The video increased students' interest in learning, in clinically applying anatomic fact, and in surgery as a future career.

Factors associated with postoperative symptoms after laparoscopic Heller myotomy.

BACKGROUND: Our objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia. METHODS: From 1994 to 2008, 261 patients undergoing laparoscopic esophageal myotomy were enrolled prospectively. The diagnosis of classic achalasia was made on clinical history, barium swallow, endoscopy, and manometry. A validated symptom questionnaire and history was taken for each patient at the preoperative visit and at each postoperative visit. RESULTS: In all, 261 patients had laparoscopic Heller myotomy during the study period. Preoperatively, 137 patients (62.3%) tried medications, 101 (38.7%) were treated with pneumatic dilation, and 29 (11.1%) were treated initially with at least one injection of botulinum toxin into the lower esophageal sphincter. In all, 134 patients (51.3%) received a Dor anterior fundoplication. On multivariate regression controlling for age and sex, preoperative dilation (p = 0.031), injection of botulinum toxin (p = 0.044), and a fundoplication (p = 0.005) were associated with significantly worse early postoperative dysphagia, with odds ratios of 2.11, 2.56, and 2.80, respectively; previous botulinum toxin injection was associated with worse late postoperative dysphagia (p = 0.001), regurgitation (p = 0.031), and heartburn (p = 0.049), with odds ratios of 5.24, 2.87, and 2.52, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn (p = 0.077) with an odds ratio of 1.80. CONCLUSIONS: Many patients presenting for Heller myotomy have previously undergone a different form of treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. Only botulinum toxin injection was associated with late symptoms.

Strategic faculty recruitment increases research productivity within an academic university division.

BACKGROUND: Research is an important mandate for academic surgical divisions. However, there is widespread concern that the current health care climate is leading to a decline in research activity. A University of British Columbia (UBC) academic surgical division attempted to address this concern by strategically recruiting PhD research scientists to prioritize research and develop collaborative research programs. The objective of our study was to determine whether this strategy resulted in increased research productivity. METHODS: We reviewed the UBC Department of Surgery database to assess research funding obtained by the Division of General Surgery for the years 1994-2004. We searched MEDLINE for peer-reviewed publications by faculty members during this period. RESULTS: Research funding increased from a mean of Can$417,292 per year in the 5 years (1994/95-1998/99) before the recruitment of dedicated PhD scientists to a mean of Can$1.3 million per year in the 5 years following the recruitment strategy (1999/2000-2003/04; p = 0.012). Funding for the initial 5 years was Can$2.1 million, including 1 Canadian Institutes of Health Research (CIHR) grant. Funding increased to Can$6.8 million, including 22 CIHR grants over the subsequent 5 years (p < 0.001). Collaborative research led to the awarding of multidisciplinary grants exceeding Can$4 million with divisional members as principle or coprinciple investigators. From 1994/05 to 1998/99, the total number of peer-reviewed publications was 116 (mean 23.2, standard deviation [SD] 7 per year), increasing to 144 from 1999/2000 to 2003/04 (mean 28.8, SD 13 per year). The trend was for publications in journals with higher impact factors in the latter 5-year period. CONCLUSION: Strategic recruitment resulted in increased and sustained research productivity. Interactions between research scientists and clinicians resulted in successful program grant funding support. These results have implications for sustaining the research mission within academic departments of surgery.

Lung nodules: CT-guided placement of microcoils to direct video-assisted thoracoscopic surgical resection.

PURPOSE: To prospectively assess the safety and effectiveness of computed tomography (CT)-guided placement of fiber-coated microcoils used to guide video-assisted thoracoscopic surgical (VATS) excision of small peripheral lung nodules, with successful excision as the primary outcome and successful CT-guided microcoil placement and procedural complications as secondary outcomes. MATERIALS AND METHODS: The institutional review board approved the study protocol. Informed consent was obtained from all 69 enrolled patients (30 men, 39 women; mean age, 60.7 years +/- 10.1 [standard deviation]) with 75 nodules. At CT, one end of an 80-mm long, 0.018-inch-diameter fiber-coated microcoil was placed deep to the small peripheral lung nodule, and the other end was coiled in the pleural space. VATS excision of lung tissue, nodules, and the microcoil was performed with fluoroscopic guidance. RESULTS: Seventy-three (97%) 4-24-mm nodules were successfully removed at fluoroscopically guided VATS excision; two nodules could not be removed. CT-guided microcoil placement was successful in all cases; however, two (3%) of 75 coils were displaced at VATS excision. Pneumothorax requiring chest tube placement occurred in two (3%) patients, and asymptomatic hemothorax occurred in one (1%) patient. The microcoil did not impede intraoperative frozen-section histopathologic analysis, which facilitated accurate clinical management in all patients. For 19 (28%) patients, the preoperative treatment plan based on bronchoscopy, needle biopsy, and positron emission tomography findings changed after VATS excision. CONCLUSION: Microcoil localization of small peripheral lung nodules enabled fluoroscopically guided VATS resection of 97% of the nodules, with a low rate of intervention (3%) for procedural complications.

The demographics of significant firearm injury in Canadian trauma centres and the associated predictors of inhospital mortality.

OBJECTIVE: Our primary objective was to evaluate demographic and causal factors of inhospital mortality for significant firearm-related injuries (i.e., those with an Injury Severity Score [ISS] > 12) in Canadian trauma centres. METHODS: We analyzed data submitted to the Canadian Institute for Health Information (CIHI) in the National Trauma Registry for all firearm-injured patients for fiscal years 1999-2003. Univariate and bivariate adjusting for ISS and multivariate logistic regression were performed. RESULTS: Men accounted for 94% of the 784 injured. In all patients, the percentages of self-inflicted, intentional, unintentional and unknown injuries were 27.8%, 60.3%, 6.1% and 5.7%, respectively. The inhospital fatality rate was 39.8%, with 83% of fatalities occurring on the first day. Two-thirds of patients were discharged home. Univariate and adjusted analysis found that ISS, first systolic blood pressure (BP), first systolic BP under 100, first Glasgow Coma Scale (GCS) score, age over 45 years, self-inflicted injury, intentional injury and injury at home significantly worsened the odds ratio of death in hospital and that police shooting was relatively beneficial. BP under 100, age over 45 years and a low GCS score had an adjusted odds ratio of death of 4.12, 1.99 and 0.64 per point increase, respectively. The multivariate model showed that ISS, BP under 100, first GCS score, sex and self-inflicted injury were significant in predicting inhospital death. CONCLUSION: A predominance of young men are injured intentionally with handguns in Canada, whereas older patients suffer self-inflicted injuries with long guns. The significant number of firearm deaths, largely in the first day, highlights the importance of preventative strategies and the need for rapid transport of patients to trauma centres for urgent care.

Empyema: an increasing concern in Canada.

BACKGROUND: Empyema is a suppurative infection of the pleural space. Without prompt treatment, it can result in significant hospital stays, more invasive treatments as it progresses, and substantial morbidity and mortality. OBJECTIVES: The primary objective of the present study was to evaluate whether there has been an increasing incidence of empyema in Canada. A secondary objective was to investigate whether this increase disproportionately affects any age group. METHODS: The Discharge Abstract Database of the Canadian Institute for Health Information was used to evaluate national empyema data. RESULTS: There were 11,294 patients identified with empyema over the nine-year period of the present study, of whom 31% were women. The mean (+/- SD) length of stay was stable throughout the study at 21.82+/-33.88 days, and 63.4% were discharged home. The incidence rate ratio (IRR) was defined as the ratio of the incidence rate of medical empyema in 2003 divided by the incidence rate in 1995. Medical empyema increased significantly (IRR 1.30, 95% CI 1.20 to 1.41; P<0.001), as did empyema of unknown cause (IRR 1.29, 95% CI 1.08 to 1.54; P=0.005), while surgical empyema did not appear to increase (IRR 1.17, 95% CI 0.97 to 1.43; P=0.114). A Poisson regression showed an increase in the indirect age-standardized IRR during the study period (IRR 1.025, 95% CI 1.018 to 1.032; P<0.001). The IRR for patients younger than 19 years of age from 1995 to 2003 was 2.20 (95% CI 1.56 to 3.10), while the IRR in patients older than 19 years was 1.23 (95% CI 1.14 to 1.34). CONCLUSIONS: The present study demonstrates the increasing rate of empyema in Canada and shows a change in pattern of disease. The disproportionate rate change in the pediatric population suggests a high-risk group that needs to be addressed. In the adult population, while cause is unknown, it is necessary to continually educate front-line physicians to confront both the increased burden of this disease, caused by an aging population, and the underlying increasing rate of empyema in Canada.

Practical approaches to the surgical management of achalasia.

Achalasia is a primary motor disorder of the esophagus characterized by an abnormal hypertensive, nonrelaxing lower esophageal sphincter (LES) and nonfunctioning, aperistaltic esophageal body resulting in significant regurgitation and dysphagia. The primary goal of treatment is palliation of symptoms. At present, all treatment techniques are directed at relieving the functional obstruction at the level of the LES by disruption or paralysis of the esophageal muscle constituting the LES. Destruction of the LES function also places the patient at risk for pathologic gastroesophageal reflux disease. Therefore, the treatment of patients with achalasia must strike a balance between the relief of dysphagia and potential creation of pathologic gastroesophageal reflux. The advent of laparoscopic esophageal myotomy for the treatment of achalasia over the past decade has resulted in most patients with the disease being referred to surgeons for definitive treatment. At the time of consultation the patient may present with a myriad of symptoms, investigative results, and previous treatments. Based on our experience of over 300 patients treated with surgery at our institution between 1990 and 2007, this review will address the practical problems encountered in the surgical management of achalasia.

The effect of clinical academic service contracts on surgeon satisfaction.

OBJECTIVE: The purpose of this study was to determine the satisfaction of members of an academic department who are funded by a Clinical Academic Service Contract (CASC), compared with those who are not. METHODS: We mailed a satisfaction questionnaire designed to examine surgeons' perceived effect of CASCs on their participation in their division or department and on professional activities (research, teaching, clinical) to members of the surgery department who perform operative interventions. We analyzed responses from CASC and non-CASC members, using t tests for continuous variables and chi-square tests for categorical variables. RESULTS: Four of 9 operative divisions (cardiac, thoracic, neurosurgery, pediatric surgery) are CASC-funded, and 5 are not (general, plastic, otolaryngology, urology, vascular). The response rate after 3 mailings was 59%. CASC responders agreed on the need for the following: improved focus and resolution of issues (p < 0.001, p < 0.02); focus on developmental and future planning (p < 0.001); flexibility to change the level of participation in research, teaching and clinical activities (p < 0.001); recognition for academic and administrative activities (p < 0.002); opportunities to achieve career path goals (p < 0.002); more autonomy in research (p < 0.04); compensation for professional activities (p < 0.001); and increased leisure time (p < 0.004). Responders disagreed that morale was low (p < 0.001). They were satisfied with the following: professional activities (p < 0.019), increased research activities (p < 0.001), quality of research (p < 0.001), more presentations (p < 0.025), increased teaching time (p < 0.004) and ability to care for their patients (p < 0.001). CONCLUSION: CASC responders were significantly more satisfied with their professional activities and more optimistic in their divisional roles than were non-CASC responders. Based on these results, all departmental members who perform operative interventions should consider being on a CASC.

Defining the optimal treatment of locally advanced esophageal cancer: a systematic review and decision analysis.

BACKGROUND: The objective of this study was to combine systematic review and decision analytic techniques to determine the optimal treatment strategy for patients with locally advanced esophageal cancer. METHODS: We performed a systematic review of all randomized trials of patients with locally advanced esophageal cancer that included one of the following strategies compared with surgery alone: chemoradiotherapy followed by surgery, chemotherapy followed by surgery, or surgery with adjuvant chemoradiotherapy. Using the estimates of relative risk for mortality and overall quality of life we constructed a decision model. The outcome of interest was expected quality-adjusted life-years (QALY). RESULTS: The meta-analysis showed for the first year, the relative risk (95% confidence interval) of death for treatments compared with surgery were 0.87 (0.75 to 1.02) for chemoradiotherapy followed by surgery, 0.94 (0.82 to 1.08) for chemotherapy followed by surgery, and 1.33 (0.93 to 1.93) for surgery with adjuvant chemoradiotherapy. The QALYs gained for surgery alone, chemoradiotherapy followed by surgery, chemotherapy followed by surgery, and surgery with adjuvant chemoradiotherapy strategies were 2.07, 2.18, 2.14, and 1.99, respectively. If the reduction in utility for multimodality treatment was increased to 21%, the QALYs gained for surgery alone, chemoradiotherapy followed by surgery, chemotherapy followed by surgery, and surgery with adjuvant chemoradiotherapy were 2.07, 2.03, 1.99, and 1.85, respectively. CONCLUSIONS: Chemoradiotherapy followed by surgery appears to be associated with the best survival and the largest expected gain in QALYs. However, the improvement in quality-adjusted life expectancy is modest at 40 days, and surgery alone becomes the preferred strategy if the reduction in utility associated with multimodality treatment is increased to 21%.

Tomographic comparison of ventilation techniques for CT-guided thoracoscopic staple excision of subcentimeter lung nodules.

This study was planned to compare the computed tomographic detectability of lung nodules in three ventilatory conditions: total lung capacity, high-frequency ventilation, and total lung deflation. In an ex vivo lung model, 44 nodules were simulated. Using computed tomography (CT) scans, nodules were detected and compared to the actual number and excised under CT guidance. Simulated nodules measured 6.2 +/- 2.1 mm and demonstrated an attenuation of 175 +/- 14 HU. Observer confidence was highest at total lung capacity (5.00 +/- 0.00), in comparison to high-frequency ventilation and total lung deflation (4.69 +/- 0.78, 4.94 +/- 0.27, p = .24). The kappa score for total lung capacity, high-frequency ventilation, and total lung deflation was 1.00, 0.96, and 0.98, respectively, indicating a very high interrater reliability. Although surgical devices generated a substantial artifact, 90% of nodules were excised. Thus, although total lung capacity produces the highest confidence level, all three of the ventilatory techniques examined have similar detection of subcentimeter pulmonary nodules using computed tomography scans.

CT-Directed microcoil localization of small peripheral lung nodules: a feasibility study in pigs.

Platinum microcoils were placed in porcine lungs to determine the feasibility for use as a lung nodule marker. Using computed tomography (CT) guidance, the microcoils were successfully deployed in 17 out of 19 attempts. Coil deployment depth ranged from 7 mm to 34 mm below the pleural surface. Moderate pneumothorax was detected after 3 of 19 microcoil insertions. No hemothorax or significant pulmonary hemorrhage was noted. Fluoroscopic guided thoracoscopic resection was successful in 10 of 12 attempts. Platinum microcoils can be safely and easily deployed into the lung parenchyma with minimal complication risk, and can be used to guide subsequent thoracoscopic wedge resection.

Peripheral lung nodules: fluoroscopically guided video-assisted thoracoscopic resection after computed tomography-guided localization using platinum microcoils.

OBJECTIVES: We sought to test the safety and efficacy of fluoroscopically guided, video-assisted, thoracoscopic resection after computed tomography (CT)-guided localization using platinum microcoils. SUMMARY BACKGROUND DATA: Video-assisted thoracoscopic (VATS) resection of small pulmonary nodules >5 mm deep to the visceral pleura fails to locate the nodule and requires conversion to open thoracotomy in two thirds of cases. Therefore, we developed a new technique for intraoperative localization of these nodules using CT-guided placement of platinum microcoils. This study tests the safety and efficacy of this technique in a Phase I human study. METHODS: Twelve patients with undiagnosed growing pulmonary nodules <20 mm were marked preoperatively using percutaneously placed CT-guided platinum microcoils. The coil was deployed adjacent to the nodule with the distal end of the coil placed deep to the nodule and the superficial end coiled on the pleural surface. The nodule and coil were excised using endostaplers guided by VATS and fluoroscopy. Histopathologic diagnosis was performed immediately after resection. RESULTS: CT-guided microcoil localization was successful in all patients. A small hemothorax and a pneumothorax requiring a chest tube occurred in 2 patients. Mean distance from visceral pleura to the deep edge of the nodule was 30.9 +/- 15.4 mm. VATS resection of the nodules (size = 11.8 +/- 3.2 mm) was successful in all patients. Mean microcoil localization, fluoroscopy, and operative times were 42 +/- 14, 3.1 +/- 2.0, and 67 +/- 27 minutes. A diagnosis of primary nonsmall cell bronchogenic carcinoma was made in 6 patients who then received a completion lobectomy. Six patients (hamartoma: 2, reactive lymph node: 1, bronchoalveolar cell carcinoma: 2, metastatic sarcoma: 1) did not receive further resections. CONCLUSIONS: Preoperative localization of pulmonary nodules using percutaneous CT-guided platinum microcoil insertion combined with operative fluoroscopic visualization is a safe, effective technique that increases the success rate of VATS excision.

The practice of thoracic surgery in Canada.

The objective of the consensus conference of the Canadian Association of Thoracic Surgeons (CATS) was to define the scope of thoracic surgery practice in Canada, to develop standards of practice, to define training and resource requirements for the practice of thoracic surgery in Canada and to determine appropriate waiting times for thoracic surgery care. A meeting of the CATS membership was held in September 2001 to address issues facing thoracic surgeons practising in Canada. The discussion was facilitated by an expert panel of surgeons and supplemented by a survey. At the end of the meeting, consensus was reached by the membership regarding the issues outline above. The membership agreed that the scope of practice includes diagnosis and management of conditions of the lungs, mediastinum, pleura and foregut. They agreed that appropriate training in thoracic surgery included completion and certification in general or cardiac surgery prior to completing a 2-year program in thoracic surgery. The membership supported the Canadian Society of Surgical Oncology recommendations for management of cancer patients that new patients should be seen within 2 weeks of referral and cancer therapy initiated within 2 weeks of consultation. Thoracic surgical care is best delivered by 2 or 3 fully certified thoracic surgeons, in regional centres linked to a cancer centre and trauma unit. The establishment of a critical mass of thoracic surgeons in each centre would lead to improved quality and delivery of care and allow for adequate coverage for on-call and continuing medical education.