Impact of Surgical Positioning on the Occurrence of Postoperative Ipilateral Shoulder Pain After Lung Resection by Video-Assisted Thoracoscopy: A Randomized Trial.

OBJECTIVE: The aim of this study was to evaluate the impact of the ipsilateral arm position on ipsilateral shoulder pain after lung cancer resection by video-assisted thoracic surgery. DESIGN: A prospective randomized controlled trial. SETTING: A single academic center study. PARTICIPANTS: Patients undergoing video-assisted thoracic surgery pulmonary resection for cancer at the Institut Universitaire de Cardiologie et de Pneumologie de Québec from May 2020 to May 2022 were included. INTERVENTIONS: Patients randomly were assigned with a 1:1 ratio to a supported or suspended ipsilateral arm position. MEASUREMENTS AND MAIN RESULTS: Ipsilateral shoulder pain incidence, pain score, and opioid use were recorded in the postanesthesia care unit (PACU) on postoperative days 1 and 2. One hundred thirty-three patients were randomized, 67 in the suspended-arm group and 66 in the supported-arm group. Of the patients, 31% reported ipsilateral shoulder pain in the PACU with no difference between groups (19/67 [28.4%] v 22/66 patients (33.3%), p = 0.5767). There was no significant difference between the pain score in the PACU (3 [0-6] v 4 [0-6], p = 0.9055) at postoperative day 1 (4 [2-6] v 3 [2-5], p = 0.4113) and at postoperative day 2 (2 [0-5] v 2 [1-4], p = 0.9508). Ipsilateral shoulder pain score decreased rapidly on postoperative day 2. There was no statistical difference in opioid and gabapentinoid use between the groups. CONCLUSIONS: Ipsilateral arm position seems to have no impact on ipsilateral shoulder pain.

Successful management of Aspergillus infection of an open window thoracostomy with topical liposomal amphotericin B.

We present the case of a previously healthy 54-year-old man who was hospitalized for an Aspergillus fumigatus infection of an open window thoracotomy. Patient was successfully treated for 8 consecutives weeks with daily topical pleural liposomal amphotericine B administered by soaked gauzes combined with systemic therapy.

Ineffective esophageal motility is not a contraindication to total fundoplication.

INTRODUCTION: Ineffective esophageal motility (IEM) is a physiologic diagnosis and is a component of the Chicago Classification. It has a strong association with gastroesophageal reflux and may be found during work-up for anti-reflux surgery. IEM implies a higher risk of post-op dysphagia if a total fundoplication is done. We hypothesized that IEM is not predictive of dysphagia following fundoplication and that it is safe to perform total fundoplication in appropriately selected patients. METHODS: Retrospective chart review of patients who underwent total fundoplication between September 2012 and December 2018 in a single foregut surgery center and who had IEM on preoperative manometry. We excluded patients who had partial fundoplication, previous foregut surgery, other causes of dysphagia or an esophageal lengthening procedure. Dysphagia was assessed using standardized Dakkak score ≤ 40 and GERD-HRQL question 7 ≥ 3. RESULTS: Two hundred patients were diagnosed with IEM and 31 met the inclusion criteria. Median follow-up: 706 days (IQR 278-1348 days). No preoperative factors, including subjective dysphagia, transit on barium swallow, or individual components of manometry showed statistical correlation with postoperative dysphagia. Of 9 patients with preoperative dysphagia, 2 (22%) had persistent postoperative dysphagia and 7 had resolution. Of 22 patients without preoperative dysphagia, 3 (14%) developed postoperative dysphagia; for a combined rate of 16%. No patient needed re-intervention beyond early recovery or required reoperation for dysphagia during the follow-up period. CONCLUSION: In appropriately selected patients, when total fundoplication is performed in the presence of preoperative IEM, the rate of long-term postoperative dysphagia is similar to the reported rate of dysphagia without IEM. With appropriate patient selection, total fundoplication may be performed in patients with IEM without a disproportionate increase in postoperative dysphagia. The presence of preoperative IEM should not be rigidly applied as a contraindication to a total fundoplication.

Minimally Invasive Esophagectomy: A Consensus Statement.

BACKGROUND: Minimally invasive esophagectomy (MIE) is increasingly performed in various ways. The lack of international definitions and nomenclature makes accurate comparison of outcomes difficult. METHODS: An international, multispecialty consensus-writing committee constructed definitions and nomenclature for MIE. After a PubMed search, vetting, and review with all authors, a consensus was reached. RESULTS: The proposed definition for MIE is an operation "that removes part or all of the esophagus, does not retract, lift, spread or remove any part of the chest or abdominal wall and the surgeon's and assistant's vision of the operative field is via a monitor, the patient's tissue is manipulated only by instruments that are controlled by the operating surgeon or team, except for during the neck portion if used." A flexible nomenclature is proposed that attempts to describe current and future operations and systems. CONCLUSIONS: Definitions and nomenclature for MIE are needed to ensure that future studies accurately compare results and outcomes of similar operations. Nomenclatures allow surgeons, researchers, and patients from different cultures to use a common language to facilitate communication and compare. This process is required in order to improve patient outcomes globally to drive adoption of best of practice, yet is lacking for MIE.

Transanal endoscopic microsurgery for rectal villous tumours: Can we rely solely on preoperative biopsies and the surgeon's experience?

Background: Transanal endoscopic microsurgery has become the standard of treatment for rectal villous adenomas. However, the role of preoperative imaging for these lesions is not clear. The aim of this study was to compare the value of preoperative imaging and surgeon clinical staging in the preoperative evaluation of patients with rectal villous adenomas having transanal endoscopic microsurgery resection. Methods: We conducted a single-centre comparative retrospective cohort study of patients who underwent transanal endoscopic microsurgery surgery for rectal villous adenomas from 2011 to 2013. The intervention was preoperative imaging versus surgeon clinical staging. The primary outcome was the accuracy of clinical staging by preoperative imaging and surgeon clinical staging according to the histopathologic staging. Results: A total of 146 patients underwent transanal endoscopic microsurgery surgery for rectal villous adenomas. One hundred and twelve (76.7%) of those patients had no preoperative imaging while 34 patients (23.3%) had either endorectal ultrasound (22 patients) or magnetic resonance imaging (12 patients). Surgeon staging was accurate in 89.3% of cases whereas staging by endorectal ultrasound was accurate in 40.9% cases and magnetic resonance imaging was accurate in 0% of cases. In the imaging group, inaccurate staging would have led to unnecessary radical surgery in 44.0% of patients. Conclusion: This study was subject to selection bias because of its retrospective nature and the limited number of patients with imaging. Patients with rectal villous tumours without invasive carcinoma on biopsies and without malignant characteristics on appearance in the judgment of an experienced colorectal surgeon might not benefit from preoperative imaging before undergoing transanal endoscopic microsurgery procedures.

Contexte: La microchirurgie endoscopique transanale est devenue le traitement standard des adénomes villeux rectaux. La valeur de l'imagerie préopératoire pour le traitement de ces lésions n'est toutefois pas bien établie. Cette étude visait à comparer l'exactitude de la stadification par imagerie préopératoire et de la stadification clinique par le chirurgien dans le cadre de l'évaluation préopératoire des patients atteints d'adénomes villeux rectaux qui subissent une résection par microchirurgie endoscopique transanale. Méthodes: Nous avons mené une étude de cohorte rétrospective comparative monocentrique chez des patients ayant subi une microchirurgie endoscopique transanale pour un adénome villeux rectal entre 2011 et 2013. Les interventions comparées étaient la stadification par imagerie préopératoire et la stadification clinique par le chirurgien. L'issue principale était l'exactitude de la stadification clinique par imagerie préopératoire et de la stadification clinique par le chirurgien, confirmée par stadification histopathologique. Résultats: Au total, 146 patients ont subi une microchirurgie endoscopique transanale pour le traitement d'un adénome villeux rectal. De ces patients, 112 (76,7 %) n'avaient pas subi d'imagerie préopératoire et 34 (23,3 %) avaient subi une échographie endorectale (22 patients) ou une imagerie par résonance magnétique (12 patients). La stadification par le chirurgien était exacte dans 89,3 % des cas, contre 40,9 % des cas pour l'échographie endorectale et 0 % des cas pour l'imagerie par résonnance magnétique. Dans le groupe ayant subi une imagerie, l'inexactitude de la stadification aurait mené à une chirurgie radicale inutile pour 44,0 % des patients. Conclusion: Cette étude comportait un biais de sélection en raison de sa nature rétrospective et du nombre limité de patients ayant subi une imagerie. L'imagerie préopératoire avant une microchirurgie endoscopique transanale pourrait ne présenter aucun avantage pour les patients présentant des tumeurs villeuses rectales dans les cas où aucun carcinome invasif n'a été détecté par biopsie et où un chirurgien colorectal chevronné n'a détecté aucune caractéristique maligne.

Short-Term and Long-Term Outcomes of Paraesophageal Hernia Repair.

The assessment of outcome after paraesophageal repair is difficult and complex. There is a wide range of reported outcomes that are not consistently defined. The focus of this article is on short-term (≤5 years) and long-term (>5 year) outcomes after laparoscopic paraesophageal repair and reviews key patient-reported outcomes (gastroesophageal reflux disease [GERD]-related and non-GERD-related symptoms), radiologic recurrence, additional therapy, and objective measurements. Overall, patients reported an excellent improvement in their quality of life after repair that remains durable. Recurrences are lower when axial and radial tension is addressed. Reoperative surgery is infrequent.

Use of veno-arterial extracorporeal membrane oxygenation in a case of tracheal injury repair in a patient with severe relapsing polychondritis.

Tracheobronchial malacia occurs in 50% of patients with relapsing polychondritis (RP), and is often managed with stent insertion. While severe complications have been described after silicone tracheal stent insertion, there are few reports describing tracheal injury in patients with RP. We present a case of tracheal perforation secondary to Dumon® stent manipulation in a patient with RP. The tracheal injury was successfully repaired with a silicone Y-stent inserted via right thoracotomy using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for ventilatory support. It is safe and feasible to introduce a silicone Y-stent through a thoracotomy for a tracheal trauma in combination with VA-ECMO support.

Transanal endoscopic microsurgery as an outpatient procedure is feasible and safe.

BACKGROUND: Transanal endoscopic microsurgery (TEM) for the excision of rectal tumor is mostly performed as an inpatient procedure. The aim of this study was to assess the feasibility and safety of TEM resection as an outpatient procedure in selected patients. POPULATION: All first 178 consecutive patients who underwent resection of a rectal tumor using TEM in our institution from April 2011 to September 2013 were included. METHOD: Standardized retrospective chart review was performed. Primary outcome was 30-day mortality and morbidity. Secondary outcomes included unplanned admission and readmission rates, operative and pathologic data. RESULTS: Of the 175 patients who underwent only TEM, 80% (140/175) were discharged the same day of surgery. There was no mortality. Morbidity rate was 31.4%. Ninety-one percent of 154 patients planned as outpatients were discharged the same day. The most common reason for unplanned admission was urinary retention (7/14; 50%). Twelve patients discharged the day of the procedure were readmitted at 30 days. Median operative time was 60 min (10-256 min). All lesions were removed with grossly negative margins with 15 positive microscopic margins on final pathology. A total of 124 adenomatous polyps and 37 malignant lesions were excised. Mean tumor diameter after fixation was 5.0 cm (range 0.5-11 cm). CONCLUSION: Transanal endoscopic microsurgery as an outpatient procedure is feasible and safe in selected patients. The main reason for unplanned admission was urinary retention in our series.