A trans-Canadian positive deviance seminar for paraesophageal hernia surgery: Reporting national postoperative outcomes and consensus recommendations.

BACKGROUND: The incidence of adverse events (AEs) and length of stay (LOS) varies significantly following paraesophageal hernia surgery. We performed a Canadian multicenter positive deviance (PD) seminar to review individual center and national level data and establish holistic perioperative practice recommendations. METHODS: A national virtual PD seminar was performed in October 2021. Recent best evidence focusing on AEs and LOS was presented. Subsequently, anonymized center-level AE and LOS data collected between 01/2017 and 01/2021 from a prospective, web-based database that tracks postoperative outcomes was presented. The top two performing centers with regards to these metrics were chosen and surgeons from these hospitals discussed elements of their treatment pathways that contributed to these outcomes. Consensus recommendations were then identified with participants independently rating their level of agreement. RESULTS: Twenty-eight surgeons form 8 centers took part in the seminar across 5 Canadian provinces. Of the 680 included patients included, Clavien-Dindo grade I and II/III/IV/V complications occurred in 121/39/12/2 patients (17.8%/5.7%/1.8%/0.3%). Respiratory complications were the most common (effusion 12/680, 1.7% and pneumonia 9/680, 1.3%). Esophageal and gastric perforation occurred in 7 and 4/680, (1.0% and 0.6% respectively). Median LOS varied significantly between institutions (1 day, range 1-3 vs. 7 days, 3-8, p < 0.001). A strong level of agreement was achieved for 10/12 of the consensus statements generated. CONCLUSION: PD seminars provide a supportive forum for centers to review best evidence and experience and generate recommendations based on expert opinion. Further research is ongoing to determine if this approach effectively accomplishes this objective.

Multicentre positive deviance seminar to generate best practice recommendations to reduce anastomotic leak and length of stay for patients undergoing oesophagectomy.

BACKGROUND: We describe a novel process using positive deviance (PD) with the Canadian Association of Thoracic Surgeons members, to identify perioperative best practice to minimise anastomotic leak (AL) and length of stay (LOS) following oesophagectomy. To our knowledge, this is the first National combination of level 1 evidence with expert opinion (ie, PD seminar) aimed at reducing AL and LOS in oesophageal surgery. Our primary hypothesis is that a multicentre National PD seminar is feasible, and could lead to the generation of best practices recommendations aimed at reducing AL and LOS in patients with oesophageal cancer. METHODS: Adverse events, LOS and AL incidence/severity following oesophagectomy were prospectively collected from seven Canadian thoracic institutions using Thoracic Morbidity and Mortality classification system (2017-2020). Anonymised display of centre's data were presented, with identification of centres demonstrating PD. Surgeons from PD sites discussed principles of care, culminating in the consensus recommendations, anonymously rated by all (5-point Likert scale). RESULTS: Data from 795 esophagectomies were included, with 25 surgeons participating. Two centres were identified as having the lowest AL rates 44/395 (11.1%) (vs five centres 71/400 (17.8%) (p<0.01)) and shortest LOS 8 days 45 (IQR: 6-14) (vs 10 days (IQR: 8-18) (p<0.001)). Recommendations included preoperative (prehabilitation, smoking cessation, chemotherapy for patients with dysphagia, minimise stents/feeding tubes), intraoperative (narrow gastric conduit, intrathoracic anastomosis, avoid routine jejunostomy, use small diameter closed-suction drains), postoperative day (POD) (early (POD 2-3) enteral feeding initiation, avoid routine barium swallow studies, early removal of tubes/drains (POD 2-3)). All ranked above 80% (4/5) in agreement to implement recommendations into their practice. CONCLUSION: We report the feasibility of a National multicentre PD seminar with the generation of best practice recommendations aimed at reducing AL and LOS following oesophagectomy. Further research is required to demonstrate whether National PD seminars can be an effective quality improvement tool.

Learning objectives for thoracic surgery: developing a national standard for undergraduate medical education.

BACKGROUND: The Continuing Professional Development (CPD) (Education) Committee of the Canadian Association of Thoracic Surgeons (CATS) has established a goal of describing the essential knowledge of thoracic surgery. We aimed to develop a national standardized set of undergraduate learning objectives for thoracic surgery. METHODS: We obtained these learning objectives from 4 medical schools in Canada. These 4 institutions were selected to provide a broad geographical representation of medical schools of varying sizes and of both official languages. The resulting list of learning objectives underwent critical review by the CPD (Education) Committee, made up of 5 Canadian community and academic thoracic surgeons, 1 thoracic surgery fellow and 2 general surgery residents. A national survey was developed and circulated to all CATS members (n = 209). Respondents were asked to indicate on a 5-point Likert scale whether each objective should be a priority for all medical students. RESULTS: Among 209 CATS members, 56 responded (response rate 27%). The mean length of experience in clinical practice among survey respondents was 10.6 (standard deviation 10.0) years. Respondents most commonly reported teaching or supervising medical students monthly (37.0%), followed by daily (29.6%). Eight of the 10 proposed objectives received a mean Likert score of 4/5 or higher and were selected for inclusion in the final list. A finalized list of 8 learning objectives was created, following a final review from the CATS Executive Committee. CONCLUSION: We developed a standardized set of learning objectives for medical students that was reflective of the core concepts within thoracic surgery.

Multicentre positive deviance to reduce adverse events and length of stay after pulmonary resection.

BACKGROUND: Postoperative adverse events (AEs) following pulmonary resection enormously impact patient well-being, length of stay (LOS) and healthcare costs. Standardised AE data collection can be used to identify positive outliers demonstrating positive deviance (PD) who may be helpful to inform the best practice. Here, we describe our initial experience of a novel quality improvement process using PD to reduce LOS and AEs. METHODS: AE rates and LOS were collected from four centres (2014-2020) using a common dictionary. Surgeons repeatedly participated in 60 to 90 min seminars consisting of the following process: identify outcome and procedure targeted, review relevant best evidence literature, view all data anonymised by surgeon or centre (if multicentre), choose and reveal identity of best performance PD outliers, who discuss their management principles while all receive self-evaluation reports, followed by collegial discussion to generate consensus recommendations, voted by all. We assessed overall impact on AEs and LOS using aggregate data in a before/after analysis. RESULTS: A total of 131 surgeons (average 12/seminar) participated in 11 PD seminars (8 local and 3 multicentre), yielding 85 consensus recommendation (average 8/seminar). Median LOS following lobectomy decreased from 4.0 to 3.0 days (p=0.04) following local PD seminars and from 4.0 to 3.5 days (p=0.11) following multicentre seminars. Trends for reductions in multiple AE rates were also observed. CONCLUSION: While limited by the longitudinal design, these findings provide preliminary support for this data-driven, collegial and actionable quality improvement process to help standardise and improve patient care, and merits further more rigorous investigation.

Co-Learning Curriculum in Quality Improvement for Surgical Residents- Five-Year Experience from the University of Toronto.

OBJECTIVE: We describe our five-year experience with a novel co-learning curriculum in quality improvement (CCQI)1 for the largest reported cohort of surgical residents. The program introduces trainees to principles of quality improvement (QI)2 and empowers them to complete collaborative projects with mentorship from faculty experts. DESIGN: Each iteration consists of three interactive seminars. Residents are required to complete and present a QI project in the third seminar. To assess the impact of the program, graduates of the 2020-2021 iteration were surveyed using validated tools to examine changes in confidence and knowledge of QI principles. SETTING: Department of Surgery, University of Toronto, Toronto, ON, Canada. PARTICIPANTS: Participation ranged from 57 to 63 residents yearly, from diverse surgical disciplines including General Surgery, Plastic Surgery, Obstetrics and Gynecology, amongst others. Multiple small groups consisted of 4-6 residents from each speciality, mentored by a faculty lead from the same specialty. RESULTS: Approximately 300 first-year surgical residents have participated in the CCQI since 2015, with over 60 completed QI projects. A total of 41(66%) and 51(82%) residents completed the survey in its pre- and post-course administration in 2020-2021, respectively. There was a significant increase in confidence scores with respect to describing a QI issue, building a team, and testing the change, amongst other aspects. There was also a statistically significant increase in mean knowledge scores for both scenarios of the Quality Improvement Knowledge Application Tool. 69% and 73% of residents reported "some improvement" in their knowledge, and confidence in applying QI principles to patient care, respectively. A majority of residents (73%) found the QI curriculum somewhat valuable, with 23% reporting it to be very valuable to their residency and future surgical career. CONCLUSIONS: We describe successful long-term implementation of a novel co-learning curriculum in quality improvement. Residents derive value from this curriculum with a meaningful increase in confidence and knowledge of QI as an integral part of surgical practice.

A Standardized Minimal Opioid Prescription Post-Thoracic Surgery Provides Adequate Pain Control.

BACKGROUND: Given the national opioid crisis, postoperative analgesia at discharge must be thoughtfully prescribed. Data specifically related to thoracic procedures remain scarce. This study assessed adequacy of pain control with standardized and limited opioids after thoracic procedures. METHODS: A standardized prescription comprised 15 hydromorphone tabs, 7 days of acetaminophen, and 3 days of ibuprofen was provided on discharge to elective thoracic surgery patients. On the first postoperative visit, patients completed a questionnaire regarding the number of hydromorphones used, use of additional opioids, pain-related limitation to function, and adequacy of pain control. RESULTS: A total of 122 patients undergoing thoracic surgery procedures were surveyed. Twelve underwent open procedures and were excluded. An additional 6 patients who used opioids chronically preoperatively were also excluded. The remaining 104 patients were included in the study. Median age was 66 years (age range, 17-90 years) and median length of stay was 2 days (range, 1-15 days). Seventeen (16%) patients used all prescribed hydromorphone and 56 (54%) used none, 18 (17%) asked for additional or other opioid, and 14 (13%) felt that their pain significantly limited their function. Nine (9%) felt that that their pain was inadequately controlled. CONCLUSIONS: Pain after thoracic procedures, especially video-assisted thoracoscopic surgery, is adequately controlled with minimal opioid doses (combined with adjuncts), with less than 1 in 5 patients requiring additional prescriptions and very few patients complaining of pain that significantly limited their function. This study shows that a standardized limited opioid prescription is safe, is adequate, and can easily be implemented for the majority of thoracic surgery patients.

Video-assisted thoracoscopic resection of a giant esophageal schwannoma: A case report.

INTRODUCTION AND IMPORTANCE: Intrathoracic schwannomas are rare and difficult to diagnose. However, they are the most common type of neurogenic tumor in the chest. Most patients are incidentally diagnosed or develop symptoms from mass effect, such as chest pain, dysphagia or dyspnea. Larger tumors have been resected using open approaches, while smaller ones are often excised with minimally invasive approaches. CASE PRESENTATION: A 60-year-old woman with a prior Roux-en-Y gastric bypass and a history of dysphagia, decreased appetite, and weight loss was referred for evaluation. CT chest revealed an 8 cm soft tissue mass centered in the distal esophagus. Gastroscopy showed the tumor to be 8 cm as well, with 2 cm of normal esophagus prior to the gastric pouch. A right-sided video-assisted thoracoscopic (VATS) approach for enucleation was successfully completed with primary esophageal repair for an 8.0 × 5.5 × 6.5 cm schwannoma. CLINICAL DISCUSSION: Surgical resection for schwannomas is often indicated due to symptoms from mass effect (Moro et al., 2017). There are reports of VATS and robotic-assisted thoracic surgery approaches for small tumors. These techniques are appealing due to shorter length of stays and less post-operative pain. None have been described for lesions larger than 6 cm. CONCLUSION: Minimally invasive approaches such as VATS for large schwannomas are technically feasible and safe to perform without the need for a thoracotomy.

Prognostic factors for cure, recurrence and long-term survival after surgical resection of thymoma.

INTRODUCTION: To determine long-term outcome and risk factors for recurrence after thymectomy. METHODS: Patients who underwent thymectomy (n = 262) for a thymic tumor (1986-2010) were identified from a prospective database. Patients were classified according to World Helath Organization (WHO) histologic classification, Masaoka staging system, and completeness of resection. Risk factors for recurrence: WHO histology, tumor size, Masaoka stage and completeness of resection were analyzed. RESULTS: Of 262 patients, 51% were female, median age was 55 years, and 39% had myasthenia gravis. Median follow-up was 7.5 years, median tumor size was 5.4 cm, and Masaoka stage distribution was: I (25%), II (47%), III (17%), IV (4%), and (7%) not classified. Of 200 patients classified under the WHO system, there were (7%) type A, (22%) type AB, and (71%) type B; 83% had complete resection. One-hundred and sixty-nine patients received adjuvant radiotherapy, eight adjuvant chemoradiotherapy and 14 neoadjuvant chemoradiotherapy. Overall survival was 95% at 5 years, 91% at 10 years and 91% at 15 years. Recurrence occurred in 12 patients and disease-related death in four patients. Five patients underwent re-resection for recurrence with survival of 2-15 years. Only Masaoka stage and tumor size were associated with statistically significant risk of recurrence on multivariate analysis. CONCLUSION: Resectable thymoma is associated with excellent prognosis. Aggressive resection of recurrent disease yielded excellent long-term results. Higher Masaoka stage is associated with a greater chance of incomplete resection. Higher Masaoka stage and increasing tumor size are independent factors associated with recurrence.

Design of a consensus-derived synoptic operative report for lung cancer surgery.

BACKGROUND: For lung cancer surgery, a narrative operative report is the standard reporting procedure, whereas a synoptic-style report is increasingly utilized by healthcare professionals in various specialties with great success. A synoptic operative report more succinctly and accurately captures vital information and is rapidly generated with good intraobserver reliability. The objective of this study was to systematically develop a synoptic operative report for lung cancer surgery following a modified Delphi consensus model with the support of the Canadian thoracic surgery community. METHODS: Using online survey software, thoracic surgeons and related physicians were asked to suggest and rate data elements for a synoptic report following the modified Delphi consensus model. The consensus exercise-derived template was forwarded to a small working group, who further refined the definition and priority designation of elements until the working group had reached a satisfactory consensus. RESULTS: In all, 139 physicians were invited to participate in the consensus exercise, with 36.7%, 44.6%, and 19.5% response rates, respectively, in the three rounds. Eighty-nine elements were agreed upon at the conclusion of the exercise, but 141 elements were forwarded to the working group. The working group agreed upon a final data set of 180 independently defined data elements, with 72 mandatory and 108 optional elements for implementation in the final report. CONCLUSIONS: This study demonstrates the process involved in developing a multidisciplinary, consensus-based synoptic lung cancer operative report. This novel report style is a quality improvement initiative to improve the capture, dissemination, readability, and potential utility of critical surgical information.

Anatomy of the thymus gland.

In the case of the thymus gland, the most common indications for resection are myasthenia gravis or thymoma. The consistency and appearance of the thymus gland make it difficult at times to discern from mediastinal fatty tissues. Having a clear understanding of the anatomy and the relationship of the gland to adjacent structures is important.

Health-related quality of life in esophageal cancer: effect of neoadjuvant chemoradiotherapy followed by surgical intervention.

OBJECTIVE: We sought to determine the effect of neoadjuvant chemoradiotherapy followed by surgical intervention on health-related quality of life in patients with esophageal cancer. METHODS: Health-related quality of life was evaluated in a prospective phase II study of neoadjuvant chemoradiotherapy followed by esophagectomy in 52 patients with carcinoma of the esophagus. Esophagectomy was performed 6 weeks after completion of induction. Functional Assessment of Cancer Therapy-Esophageal scoring was performed before treatment, 7 weeks after initiation of neoadjuvant therapy, before resection, and at 1, 3, and 6 months and 1 year after resection. RESULTS: Forty-three patients completed the entire treatment protocol. Functional Assessment of Cancer Therapy-Esophageal scores decreased significantly after chemoradiation at week 7 (120 vs 127 at baseline, P = .04) but returned to baseline levels before surgical intervention (127). Similarly, scores decreased significantly after surgical intervention (115 at 1 month, P = .02) but returned to baseline levels by 3 months postoperatively (127). At 1 year postoperatively, there was a statistically significant improvement in scores compared with those at baseline (139, P = .003). Functional Assessment of Cancer Therapy-Esophageal scores continued to increase over time for patients who were alive at least 1 year after the operation with or without disease but were observed to significantly decrease in those who died within 1 year after the operation (P = .0001). An increase in quality of life was associated with a significantly lower risk of death (P = .04). CONCLUSION: Neoadjuvant therapy has a significant effect on health-related quality of life, but this is transient, with recovery to baseline within 5 to 7 weeks after completion of induction therapy. Health-related quality of life decreases again after surgical intervention but returns to baseline levels within 3 months.