Implementing a one-day testing model improves timeliness of workup for patients with lung cancer.

Background: Patients with lung cancer often experience stressful delays throughout the diagnostic phase of care. To address that situation, our multidisciplinary team created a "Navigation Day," during which patients partake in a single-day visit that comprises nurse-led teaching, social work, smoking cessation counselling, symptom control, and dedicated test slots for integrated positron-emission tomography and computed tomography (pet/ct), pulmonary function tests (pfts), and magnetic resonance imaging (mri) of the brain. We evaluated the effects of that program on wait times and patient satisfaction. Methods: Patients with a suspicion of lung cancer on chest ct imaging referred during 3 time periods were reviewed: 1 year before launch of the Navigation Day, 1 year post-launch, and 2 years post-launch. Patients were further stratified according to concordance of their test date with a Navigation Day date. Mean wait times for pet/ct, pfts, and mri brain were calculated for each group. Patient satisfaction was measured using a standardized provincial survey. The Student t-test and analysis of variance were used to assess for significance. Results: After implementation, mean wait times in the first year improved to 9.2 days from 15.5 days for pet/ct (p < 0.0001), to 9.6 days from 15.7 days for pfts (p < 0.0001), and to 10.2 days from 16.0 days for mri brain (p < 0.0001). Patients who used a dedicated test slot experienced the shortest wait times, at 5.8 days for pet/ct, 5.8 days for pfts, and 6.3 days for mri brain (p < 0.0001). Those improvements were sustained at 2 years post-launch. Patient satisfaction in the categories of assistance, emotional support, and clarity remained high post-launch. Conclusions: Navigation Day significantly improved the timeliness of diagnostic testing services in patients with suspected lung cancer.

Midpoint transverse process to pleura catheter placement for postoperative analgesia following video-assisted thoracoscopic surgery.

The ultrasound-guided midpoint transverse process to pleura block has been described as an alternative end-point for thoracic paravertebral blockade. Although originally described as a single-level block, midpoint transverse process to pleura blockade may cover more than one level when larger volumes of injectate are used. Moreover, a continuous catheter midpoint transverse process to pleura blockade technique was previously thought to be unfeasible. We report three cases where a midpoint transverse process to pleura continuous catheter technique was successfully used for postoperative analgesia following video-assisted thoracoscopic surgery.

Regional process redesign of lung cancer care: a learning health system pilot project.

BACKGROUND: The Ottawa Hospital (toh) defined delay to timely lung cancer care as a system design problem. Recognizing the patient need for an integrated journey and the need for dynamic alignment of providers, toh used a learning health system (lhs) vision to redesign regional diagnostic processes. A lhs is driven by feedback utilizing operational and clinical information to drive system optimization and innovation. An essential component of a lhs is a collaborative platform that provides connectivity across silos, organizations, and professions. METHODS: To operationalize a lhs, we developed the Ottawa Health Transformation Model (ohtm) as a consensus approach that addresses process barriers, resistance to change, and conflicting priorities. A regional Community of Practice (cop) was established to engage stakeholders, and a dedicated transformation team supported process improvements and implementation. RESULTS: The project operationalized the lung cancer diagnostic pathway and optimized patient flow from referral to initiation of treatment. Twelve major processes in referral, review, diagnostics, assessment, triage, and consult were redesigned. The Ottawa Hospital now provides a diagnosis to 80% of referrals within the provincial target of 28 days. The median patient journey from referral to initial treatment decreased by 48% from 92 to 47 days. CONCLUSIONS: The initiative optimized regional integration from referral to initial treatment. Use of a lhs lens enabled the creation of a system that is standardized to best practice and open to ongoing innovation. Continued transformation initiatives across the continuum of care are needed to incorporate best practice and optimize delivery systems for regional populations.

Esophagectomy in esophageal perforations: an analysis.

This study aimed to study the factors that are associated with urgent esophagectomy for the treatment of esophageal perforations and the impact of this therapy. A retrospective review of all esophageal perforations treated at a tertiary care hospital from January 1984 to January 2012 was performed. Compiling demographics, cause and site of perforations, time to presentation, comorbidities, radiological tests, the length of perforation, the hemodynamic status of the patient, type of treatment required, and outcomes were performed. Univariate, multivariate, and Cox regression analyses were conducted. Of 127 cases of esophageal perforation, it was spontaneous in 44 (35%), iatrogenic in 53 (44%), foreign body ingestion in 22 (17%), and traumatic perforation in 7 (6%) cases. Overall, 85 of the 127 (67%) patients were managed operatively, 35 (27.6%) patients were treated conservatively, and 7 (6.3%) patients were treated by endoscopic stent placement. Of the 85 patients who were managed operatively, 21 (16.5%) required esophagectomies, 13 (15.3%) had esophagectomy with immediate reconstruction, 5 (5.9%) patients had esophagectomy followed by delayed reconstruction, and 3 (3.5%) patients failed primary repair and required an esophagectomy as a secondary definitive procedure. Multivariate analysis revealed that esophagectomy in esophageal perforations was associated with the presence of benign or malignant esophageal stricture (P = 0.001) and a perforation >5 cm (P = 0.001). Mortality was mainly associated with the presence of a benign or malignant esophageal stricture (P = 0.04). The presence of pre-existing benign or malignant stricture or large perforation (>5 cm) is associated with the need for an urgent esophagectomy with or without immediate reconstruction. Performing esophagectomy was not found to be a significant prognosticator for mortality.

A prospective study of peri-diagnostic and surgical wait times for patients with presumptive colorectal, lung, or prostate cancer.

The objective of this study was to prospectively measure peri-diagnostic and surgical time intervals for patients with suspected colorectal, lung, or prostate cancer. Prospective eligible patients were referred to a regional hospital in Ottawa, Canada between February 2004 and February 2005 for diagnostic assessment of presumptive colorectal, lung, or prostate cancer. Chart abstractions were used to measure nine time intervals; the primary interval was the date of referral for diagnostic assessment to the date the patient was informed of the diagnosis. Health-related quality-of-life (HRQL) was assessed 5 days following the patient being informed of their diagnosis. The median (IQR) time for the primary interval was 71 (30-110), 37 (29-49), and 81 (56-100) days for colorectal, lung, and prostate patients, respectively (Kruskal-Wallis P=0.0001). This interval was significantly less for colorectal patients diagnosed with cancer than for those without cancer (median difference=59.0 days; Wilcoxon P=0.003). No differences in HRQL existed for patients with cancer and those without. Colorectal and prostate patients wait longer between referral for suspected cancer and being informed of their diagnosis than current recommendations. The shorter diagnostic intervals for colorectal patients with cancer suggest clinicians have an effective process for triaging patients referred for diagnostic assessment.

Esophageal perforation: a rare complication of Zollinger-Ellison syndrome.

Spontaneous perforation of the esophagus is a rare manifestation of Zollinger-Ellison syndrome (ZES). Failure to recognize its existence can lead to an unsuccessful treatment of the esophageal perforation. We present a rare case of reflux esophagitis-induced esophageal perforation in a patient with ZES. Presence of a gastrinoma should be considered when recurrent or complicated reflux esophagitis is encountered.

Glomus tumor of the trachea.

Extracutaneous glomus tumors are uncommon and rarely occur in the trachea. We describe a 73-year-old man with a glomus tumor of the trachea who presented with cough, dyspnea, chest pain, and hemoptysis. A curative segmental tracheal resection with primary reconstruction was performed with no recurrence at 6-year follow-up. The clinicopathologic features of this unusual neoplasm are discussed with a review of the literature.

Transthoracic needle biopsy of the lung: results of early discharge in 506 outpatients.

PURPOSE: To determine the safety of early discharge (30 minutes) after transthoracic needle biopsy (TTNB) of the lung. MATERIALS AND METHODS: In a prospective study of 506 consecutive outpatients who underwent TTNB of the lung, 440 patients underwent fine-needle aspiration biopsy (FNAB) only, and 66 underwent FNAB and core biopsy. Patients were discharged after 30-minute postbiopsy chest radiography if there was no pneumothorax. Patients were discharged after 60-minute chest radiography if they had a stable asymptomatic pneumothorax. These patients were followed up 1 day and/or 1 week after biopsy to identify delayed complications. Patients with a symptomatic or enlarging pneumothorax were treated with an 8-F pigtail catheter attached to a Heimlich valve, discharged, and followed up 24 hours later for chest tube removal. RESULTS: The pneumothorax rate was 22.9% (116 patients). Eighty-one patients (16.0%) had an asymptomatic pneumothorax, and 33 (6.5%) had a pigtail catheter in place. Seven (1.4%) patients developed a symptomatic pneumothorax after discharge; two of them (0.4%) underwent large-bore chest tube insertion. The other five (1.0%) underwent delayed pigtail catheter insertion. There were no deaths or other major complications. CONCLUSION: Early discharge after outpatient TTNB of the lung is associated with little morbidity and no mortality.

The stomach as a microvascularly augmented flap for esophageal replacement.

We present a case of difficult esophageal reconstruction after total esophagectomy for iatrogenic perforation in a diseased esophagus. The stomach was used for esophageal reconstruction as a retrosternal microvascularly augmented flap; the vascular supply to the stomach had been interrupted during previous abdominal operations. The blood supply to the stomach conduit was restored by separate arterial and venous anastomosis between the right internal thoracic vessels and the left gastric vessels.

Cervical mediastinoscopy incisional metastasis.

Tumor deposit in the cervical mediastinoscopy incision is a rare complication of this operation when it is done to stage lung cancer. The etiology of this complication remains unclear. We present the case of a patient with this condition, discuss the cause and management, and review the literature.

Clinical characteristics and the impact of surgery and chemotherapy on survival of patients with advanced and metastatic bronchioloalveolar carcinoma: a retrospective study.

We retrospectively analyzed data from the clinical charts of 126 patients with bronchioloalveolar carcinoma (BAC) referred to the Ottawa Regional Cancer Center. The patient group consisted of 49 men (39%) and 77 women (61%). The mean age at diagnosis was 64 years. Most patients were smokers (85%). At diagnosis, 53% were stage Ia-IIIa and 47% were stage IIIb and IV. Forty-one percent of the patients with advanced and metastatic stages (IIIb, IV) underwent surgery. Multifocal disease was present at diagnosis in 41% of the patients, including 6% who had stage IIIb multifocal disease confined to a single lobe. Surgery was associated with prolonged survival in patients with multifocal unilobar or multilobar disease (P = 0.0001). While this apparent benefit of surgery may have been due to selection bias, it supports further exploration of surgery as therapy for multifocal disease. While patients receiving chemotherapy for advanced disease did not survive longer than patients not receiving chemotherapy, chemotherapy was used primarily in patients with more aggressive disease, suggesting that selection bias may have contributed to its apparent lack of benefit. Of the 30 patients treated with chemotherapy, only 3 (10%) achieved an objective response. One third of the patients (34%) developed distant metastases, with a predilection for the brain and bone.

Angiosarcoma of the chest wall.

Angiosarcoma is a rare and highly malignant tumor of vascular origin. The causative factors include trauma, radiation, foreign bodies, thorium dioxide, and viral infections. We report a case of angiosarcoma occurring in a thoracotomy incision 17 years after operation for stage I lung cancer.

The timing of tracheotomy: a systematic review.

STUDY OBJECTIVE: To examine the impact of the timing of tracheotomy on the duration of mechanical ventilation, the secondary changes to the trachea, and the clinical course of critically ill patients in the ICU. DESIGN: A systematic review of the literature. METHODS: Two independent reviewers conducted a MEDLINE search for relevant literature in the form of randomized or observational controlled clinical studies. Studies were selected for review by criteria determined a priori; and the methodologic quality of selected studies was evaluated by duplicate independent review, also using criteria determined a priori. RESULTS: Five studies were identified, of which three were quasirandomized and none were blinded. Agreement between reviewers of methodologic quality was high (kappa=0.87). CONCLUSIONS: There is insufficient evidence to support that the timing of tracheotomy alters the duration of mechanical ventilation or extent of airway injury in critically ill patients.

The impact of multiple organ dysfunction on mortality following ruptured abdominal aortic aneurysm repair.

The in-hospital mortality for a patient with a ruptured abdominal aortic aneurysm (RAAA) ranges from 30% to 70% and remains unchanged despite aggressive surgical, anesthetic, and intensive-care management. The purpose of this investigation is to determine the relationship between the development of organ dysfunction and mortality in ruptured AAA patients. Eighty-eight consecutive patients admitted to the Toronto Hospital for repair of RAAAs were studied. APACHE II and multiple organ dysfunction (MOD) scores were calculated for all patients. The MOD scoring system measures daily alterations in the function of six key organs, with increased dysfunction indicated by an increasing score. The overall 30-day mortality rate was 40%; 10% of patient deaths occurred intraoperatively. ICU mortality was bimodal; 11.5% deaths occurred within the first 48 hours compared to 18.2% after 48 hours (late deaths). The APACHE II score was significantly higher in those who died within 48 hours of ICU admission (28.5 +/- 6.36) compared to both those who died late (17.2 +/- 5.7, p < 0.0001) and survivors (11.2 +/- 4.2, p < 0.0001). The survivors' daily mean MOD scores did not increase significantly, while the MOD scores for late deaths increased progressively (p < 0.01). The renal and hepatic dysfunction components of the MOD score were significantly lower in the survivors compared to late deaths (p < 0.001), however the respiratory MOD score did not differ between the groups (p > 0.05). The change in MOD (delta MOD) score over the intensive care stay was significantly greater in late deaths compared to survivors (p < 0.01). The rates of infection were similar in both groups and were not responsible for mortality. We conclude that mortality is better predicted following RAAA by the development of renal and hepatic dysfunction rather than by initial physiologic derangement measured by the APACHE II score.

Massive hiatus hernia: evaluation and surgical management.

OBJECTIVE: Paraesophageal hernias represent advanced degrees of sliding hiatus hernia with intrathoracic displacement of the intraesophageal junction. Gastroesophageal reflux disease occurs in most cases, resulting in acquired short esophagus, which should influence the type of repair selected. METHODS: Between 1960 and 1996, 94 patients with massive, incarcerated paraesophageal hiatus hernia were operated on at the Toronto General Hospital. The mean age was 64 years (39 to 85 years), with a female to male ratio of 1.8:1. Organoaxial volvulus was present in 50% of cases. Clinical presentation in these patients included postprandial pain in 56%, dysphagia in 48%, chronic iron deficiency anemia in 38%, and aspiration in 29%. Symptomatic reflux, either present or remote, was recorded in 83% of cases. All patients underwent endoscopy by the operating surgeon. In 91 of 94 patients, the esophagogastric junction was found to be above the diaphragmatic hiatus, denoting a sliding type of hiatus hernia. Gross, endoscopic peptic esophagitis was observed in 36% of patients: ulcerative esophagitis in 22% and peptic esophagitis with stricture in 14%. A complete preoperative esophageal motility study was obtained for 41 patients. The lower sphincter was hypotensive in 21 patients (51%), and the amplitude of peristalsis in the distal esophagus was diminished in 24 patients (59%). These abnormalities are both features of significant gastroesophageal reflux disease. In 13 recent, consecutive patients with paraesophageal hernia, the distance between the upper and lower esophageal sphincters was measured during manometry. The average distance was 15.4 +/- 2.33 cm (11 to 20 cm), which is consistent with acquired short esophagus. The normal distance is 20.4 cm +/- 1.9 (p < 0.0001). RESULTS: All 94 patients were treated surgically: 97% had a transthoracic repair with fundoplication. A gastroplasty was added in 75 cases (80%) because of clearly defined or presumed short esophagus. There were two operative deaths, and two patients were never followed up. Among the 90 available patients, the mean follow-up was 94 months; median follow-up was 72 months. Seventy-two patients (80%) are free of symptoms (excellent result); 13 (13%) have inconsequential symptoms requiring no therapy (good result); and three patients (4%) are improved but have symptoms requiring medical therapy or interval dilatation (fair result). Two patients had poor results because of recurrent hernia and severe reflux. Both were successfully treated by reoperation with the addition of gastroplasty because of acquired shortening, which was not recognized at the first operation. CONCLUSIONS: Most of these 94 patients had symptoms or endoscopic, manometric, and operative findings that were consistent with a sliding hiatus hernia. There was a high incidence of endoscopic reflux esophagitis and of acquired short esophagus. True paraesophageal hernia, with the esophagogastric junction in a normal abdominal location, appears rare. Our observations were supported by measurements obtained at preoperative endoscopy and manometry, and by findings at the time of surgical repair. These observations support the choice of a transthoracic approach for repair in most patients.

Postpneumonectomy syndrome: recognition and management.

STUDY OBJECTIVE: Postpneumonectomy syndrome (PPS) results from extreme shift and rotation of the mediastinum after pneumonectomy producing symptomatic proximal airway obstruction and air trapping. Herein, we review our experience in the treatment of PPS. PATIENTS: Five patients with PPS were treated at our institution between 1991 and 1997. Four patients had previous right pneumonectomy; one patient had left pneumonectomy. Dyspnea was the presenting symptom in all five patients. The time interval to onset of symptoms and to surgical correction ranged from 6 months to 9 years (median: 6 months) and 9 months to 29 years (median, 21 months) after pneumonectomy, respectively. INTERVENTION: The clinical diagnosis of PPS was confirmed with chest radiograph, two-dimensional echocardiography, pulmonary function tests, CT scan, and awake fiberoptic bronchoscopy. Correction of PPS required reexploration of the pneumonectomy space followed by anterior pericardiorrhaphy and insertion of a saline solution-filled Silastic prosthesis (Dow Corning; Midland, MI) for the purpose of correcting the overshift of the mediastinum. There was no morbidity or mortality. RESULTS: All patients had relief of dyspnea. Corrective repositioning of the mediastinum was confirmed by chest radiograph, CT scan, and awake fiberoptic bronchoscopy. There was a mean increase in the cross-sectional diameter, as measured by CT scan, of the obstructed bronchus by 166.7% (range, 100 to 300%) in four patients. One patient had no change in the measured diameter. Postoperatively, the peak expiratory flow rate increased by a mean of 44.2% (range, 40 to 49%) in all five patients. CONCLUSION: The presence of PPS should be considered in all patients presenting with progressive dyspnea after pneumonectomy. Repositioning of the mediastinum with a saline solution-filled prosthesis and anterior pericardiorrhaphy is easily performed and provides immediate and lasting symptomatic relief.

Adenoid cystic carcinoma of the airway: thirty-two-year experience.

METHODS: We have reviewed our experience in 38 patients with adenoid cystic carcinoma of the upper airway seen between 1963 and 1995. The mean age was 44.8 years (15 to 80 years) with a male/female ratio of 1:1.1. Thirty-two of the 38 patients were treated by resection and reconstruction (primary anastomosis 28; Marlex mesh prosthesis 4). Twenty-six of the 32 patients undergoing resection received adjuvant radiotherapy. Six patients with unresectable tumors were treated primarily with radiotherapy only. RESULTS: Pathologic examination revealed local invasion beyond the wall of the trachea in all patients. In a majority, microscopic extension was found in submucosal and perineural lymphatics, well beyond the grossly visible or palpable limits of the tumor. Lymphatic metastases were relatively uncommon, occurring in only five of 32 (19%) patients undergoing resection. Metachronous hematogenous metastases occurred in 17 of 38 patients (44%). Thirteen of these 38 patients (33%) had pulmonary metastases. Sixteen of 32 resections were complete and potentially curative. There were two deaths within 30 days of operation. The mean survival in the 14 patients undergoing complete resection was 9.8 years (12 months to 29 years). Sixteen of 32 resections were incomplete (residual tumor at the airway margin on final pathologic examination), with one operative death occurring in this group. The mean survival in the 15 surviving patients was 7.5 years (4 months to 21 years). Six patients were treated with primary radiation only and had a mean survival of 6.2 years (2 months to 14.3 years). In the patients with pulmonary metastases, mean survival was 37 months (4 months to 7 years) from the time of diagnosis of the pulmonary metastasis until their death. CONCLUSION: Adenoid cystic carcinoma of the upper airway is a rare tumor, which is locally invasive and frequently amenable to resection. Although late local recurrence after resection is a feature of this tumor (up to 29 years), excellent long-term palliation is commonly achieved after both complete and incomplete resection. There was a small difference in survival between patients having complete and incomplete resection. Long periods of control can be obtained with radiotherapy alone. The best results, in this series of patients, were obtained by resection. Adjuvant radiotherapy is assumed to favorably influence survival.

Extrathoracic angiomyolipomas in lymphangioleiomyomatosis.

Pulmonary lymphangioleiomyomatosis (LAM) is a rare disorder that affects women and can lead to serious respiratory impairment. Since Bourneville's tuberous sclerosis (TS) was first reported, the striking similarities between the two entities have led many to believe that LAM is a forme fruste of TS. This is suggested by reports that angiomyolipomas, rare tumours in themselves, are reported in 40-80% of TS patients and occur in 15-30% of LAM patients. A retrospective chart review was conducted of 14 patients that presented to our institution with a diagnosis of LAM. We sought to document the clinical manifestations, particularly the incidence and location of extrathoracic tumours, in order to further support the hypothesis that LAM is a forme fruste of TS. Twelve patients had premenopausal onset of symptoms and two postmenopausal. The diagnosis was confirmed histologically (n = 12) and/or by computed tomography (CT) scan of the thorax (n = 12). Imaging investigations revealed extrathoracic tumours in 12 of 14 patients (86%). Eight of the 14 patients (57%) had renal tumours consistent with angiomyolipomas (bilateral in five patients). Only one patient had renal symptoms (flank pain and haematuria). All had normal serum creatinine, one had a reduced creatinine clearance. Extrathoracic nonrenal tumours were discovered in the pancreas, adrenals and uterus, findings previously unreported in LAM. In summary, the incidence of extrathoracic tumours in lymphangioleiomyomatosis patients is much higher than previously reported in the literature. This increased association supports the theory that lymphangioleiomyomatosis and tuberous sclerosis represent part of a spectrum of a similar disease process.

Can patients with left main stenosis wait for coronary artery bypass grafting?

BACKGROUND: The economic impact of health care reforms may result in waiting lists for coronary artery bypass grafting. This study was designed to examine the clinical results of patients with left main stenosis who were placed on a triaged wait list for operation. METHODS: Data were collected prospectively on 2,145 patients undergoing isolated coronary artery bypass grafting between 1989 and 1994. Critical left main stenosis (LMS, 50% or more stenosis) was present in 281 patients, and 1,864 patients had no left main disease, or a left main stenosis of less than 50% (no LMS). RESULTS: The average time from angiography to operation was shorter in patients with LMS (LMS 38 +/- 46 days versus no LMS 84 +/- 71 days; p = 0.0001). Two patients in the LMS group died; they had declined operation. Four patients suffered non-Q wave myocardial infarctions, all of whom subsequently underwent operation with no perioperative complications. The presence of LMS did not influence operative mortality (LMS 2.8% versus no LMS 1.3%), the incidence of low output syndrome (LMS 8.3% versus no LMS 5.4%), or the incidence of perioperative myocardial infarction (LMS 3.8% versus no LMS 4.2%). To examine the effect of waiting time on outcomes, patients with LMS were divided into early (operation 10 days or less after angiography) and late revascularization groups (more than 10 days). Operative mortality, low output syndrome, and myocardial infarction were similar in the early and late groups. Patients in the early group were more likely to have New York Heart Association functional class IV symptoms (64% versus late 22%; p < 0.0001), unstable angina (87% versus late 65%; p < 0.0001), or a recent preoperative myocardial infarction (17% versus late 2%; p < 0.0001). CONCLUSIONS: Carefully selected patients with significant left main stenosis can safely wait for operation with a low risk of complications. Early surgical intervention is allocated to patients with severe symptoms or recent preoperative myocardial infarction.