Molecular analysis of endobronchial ultrasound needle aspirates in patients with non-small cell lung cancer: Results from the SCOPE database.

OBJECTIVE: Molecular subtyping of non-small cell lung cancer (NSCLC) is critical in the diagnostic evaluation of patients with advanced disease. This study aimed to examine whether samples from endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of intrathoracic lymph nodes and/or lung lesions are adequate for molecular analysis across various institutions. METHODS: We retrospectively reviewed all cases of linear EBUS-TBNA with a final bronchoscopic diagnosis of NSCLC entered in the Stather Canadian Outcomes registry for chest ProcEdures database. The primary outcome was specimen inadequacy rate for each molecular target, as defined by the local laboratory or pathologist. RESULTS: A total of 866 EBUS-TBNA procedures for NSCLC were identified. Specimen inadequacy rates were 3.8% for EGFR, 2.5% for ALK-1 and 3.5% for PD-L1. Largest target size was not different between adequate and inadequate specimens, and rapid onsite evaluation did not increase specimen adequacy rates. One centre using next-generation sequencing for EGFR had lower adequacy rates than 2 others using matrix-assisted laser desorption/ionization time-of-flight mass spectrophotometry. CONCLUSION: EBUS-TBNA specimens have a very low-specimen inadequacy rate for molecular subtyping of non-small cell lung cancer.

Endobronchial Ultrasound Transbronchial Needle Aspiration With a 19-Gauge Needle vs 21- and 22-Gauge Needles for Mediastinal Lymphadenopathy.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly used to evaluate mediastinal lymphadenopathy. Studies focusing on malignant lymphadenopathy have compared 21- and 22-gauge (21G and 22G, respectively) needles and have not identified an advantage of one needle size over the other in terms of diagnostic yield. RESEARCH QUESTION: Does the 19-gauge (19G) EBUS needle offer greater diagnostic yield and sensitivity vs the 21G and 22G EBUS needles for a diagnosis of sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed? STUDY DESIGN AND METHODS: This study retrospectively examined records of 730 patients from the Stather Canadian Outcomes Registry for Chest Procedures (SCOPE) database who underwent EBUS-TBNA for a diagnosis of suspected sarcoidosis, lymphoma, or mediastinal lymphadenopathy not yet diagnosed. A propensity score analysis of two groups was performed. One group comprised patients undergoing EBUS-TBNA with a 19G needle, the other with a 21G or 22G needle. Cases for analysis were selected with a 1:2 ratio of 19G vs 21/22G using logistic regression and random matching with all eligible 19G cases included. RESULTS: There were 137 patients (312 targets) in the 19G group and 274 patients (631 targets) in the 21/22G group in the propensity score analysis. The diagnostic yield was 107 of 137 (78.1%) in the 19G group vs 194 of 274 (70.8%) in the 21/22G group (difference, 7.3%; 95% CI, -1.9 to 15.6; P = .116). The sensitivity of EBUS-TBNA for sarcoidosis was 80 of 83 (96.4%) in the 19G group vs 150 of 156 (96.2%) in the 21/22G group (difference, 0.24%; 95% CI, -6.6 to 85.1; P = .93). In patients with a final diagnosis of lymphoma, EBUS was diagnostic in 10 of 13 (76.9%) in the 19G group vs 12 of 12 (100%) in the 21/22G group (difference, 23.1%; 95% CI, -5.4 to 50.3; P = .08). INTERPRETATION: The study did not identify an advantage of the 19G EBUS needle over the 21/22G EBUS needles for diagnostic yield nor sensitivity for sarcoidosis or lymphoma.

Lung hemorrhage in trauma: Technical tricks and tips.

At some point as the on-call trauma surgeon, you may need to operate on a bleeding lung. This concise review addresses preoperative and intraoperative considerations for traumatic lung injuries, including how to deal with specific findings at the time of surgery.

Protocol for the Stather Canadian Outcomes Registry for Chest ProcedurEs (SCOPE).

INTRODUCTION: The Stather Canadian Outcomes registry for chest ProcedurEs (SCOPE registry) is a Canadian multicentre registry of chest procedures. METHODS AND ANALYSIS: The SCOPE registry is designed as a multicentre prospective database of specific bronchoscopic or other pulmonary procedures. Each procedure of interest will be associated with a registry module, and data capture designed to evaluate effectiveness of procedures on relevant patient outcomes. Participating physicians will be asked to enter data for all procedures performed in a given module. The anonymised dataset will be housed in a web-based electronic secure database. Specific modules included will be based on participating physician suggestions, capacity and consensus of the steering committee and relevance of hypotheses/research potential. ETHICS AND DISSEMINATION: The central registry is under approval from the Conjoint Health Research Ethics Board at the University of Calgary. We aim for registry data to lead to publication of manuscripts in international medical journals as the primary mode of dissemination. Data may also be used by local investigators for personal and/or institutional quality control purposes as well as to inform health policies. Data requests from non-participating investigators for use under ethics approved research protocols can be considered.

Development of a clinical score to distinguish malignant from benign esophageal disease in an undiagnosed patient population referred to an esophageal diagnostic assessment program.

BACKGROUND: Esophageal cancer is associated with poor prognosis. Diagnosis is often delayed, resulting in presentation with advanced disease. We developed a clinical score to predict the risk of a malignant diagnosis in symptomatic patients prior to any diagnostic tests. METHODS: We analyzed data from patients referred to a regional esophageal diagnostic assessment program between May 2013 and August 2016. Logistic regression was performed to identify predictors of malignancy based on patient characteristics and symptoms. Predicted probabilities were used to develop a score from 0 to 10 which was weighted according to beta coefficients for predictors in the model. Score accuracy was evaluated using a receiver operating characteristic (ROC) curve and internally validated using bootstrapping techniques. Patients were classified into low (0-2 points), medium (3-6 points), and high (7-10 points) risk groups based on their scores. Pathologic tissue diagnosis was used to assess the effectiveness of the developed score in predicting the risk of malignancy in each group. RESULTS: Of 530 patients, 363 (68%) were diagnosed with malignancy. Factors predictive of malignancy included male sex, family history of cancer and esophageal cancer, fatigue, chest/throat/back pain, melena and weight loss. These factors were allocated 1-2 points each for a total of 10 points. Low-risk patients had 70% lower chance of malignancy (RR =0.28, 95% CI: 0.21-0.38), medium-risk had 50% higher chance of malignancy (RR =1.5, 95% CI: 1.26-1.77), and high-risk patients were 8 times more likely to be diagnosed with malignancy (RR =8.2, 95% CI: 2.60-25.86). The area under the ROC curve for malignancy was 0.82 (95% CI: 0.77-0.87). CONCLUSIONS: A simple score using patient characteristics and symptoms reliably distinguished malignant from benign diagnoses in a population of patients with upper gastrointestinal symptoms. This score might be useful in expediting investigations, referrals and eventual diagnosis of malignancy.

Development and Pilot Testing of an Assessment Tool for Performance of Anatomic Lung Resection.

BACKGROUND: To meet the need for competency assessment in thoracic surgery education, we developed and tested an instrument to assess trainees' ability to perform anatomic lung resection for cancer. METHODS: The Thoracic Competency Assessment Tool-Anatomic Resection for Lung Cancer (TCAT-ARC) was developed through a multistep process involving logical analysis, expert review, and simulation-based and clinical pilot testing. Validity evidence was gathered during a 6-month clinical study of trainees performing anatomic lung resections and assessments of practicing surgeons. Feedback was gathered via post-encounter questionnaires. RESULTS: A 35-item instrument was developed and was tested in the clinical validation study. Seven trainees in 4 North American institutions participated and completed 64 anatomic lung resections. Reliability was high (α = 0.93). Interobserver reliability (k = 0.73) and correlation with an existing global competency scale (k = 0.68) were moderately high. Item analysis revealed the most difficult and discriminatory items, which matched well with a conceptual understanding of lung resection. Both trainees and assessors viewed the instrument as highly educationally effective and user-friendly. Practicing surgeons outperformed trainees. CONCLUSIONS: The TCAT-ARC demonstrated early evidence of validity and reliability in assessing performance of anatomic lung resection. The instrument may be most useful early in training and as a means for providing fine-grained formative feedback about which steps have been mastered and which still require improvement. The TCAT-ARC may be used in training programs to aid in the development of trainees' competency and as a part of an aggregate assessment of trainees' overall mastery of the procedure and readiness for independent practice.

Development and Pilot Testing of an Assessment Tool for Performance of Invasive Mediastinal Staging.

BACKGROUND: To develop and evaluate a surgical trainee competency assessment instrument for invasive mediastinal staging, including cervical mediastinoscopy and endobronchial ultrasound (EBUS), a comprehensive instrument was developed, the Thoracic Competency Assessment Tool-Invasive Staging (TCAT-IS), using expert review and simulated and clinical pilot-testing. METHODS: Validity and reliability evidence were collected, and item analysis was performed. Initially, a 27-item instrument was developed, which underwent expert review with members of the Canadian Association of Thoracic Surgeons (n = 86) in 2014 to 2015 (response rate, 57%). TCAT-IS was refined to 29 items in 4 competency areas: preoperative, general operative, mediastinoscopy, and EBUS. Further refinements were made based on simulated use. The final version was then used to assess competency of 5 thoracic trainees performing invasive mediastinal staging in live patients. RESULTS: Participants were assessed during 20 mediastinoscopy and 8 EBUS procedures, with 47 total assessments completed. Reliability (Cronbach's alpha = 0.94), interrater reliability (κ = 0.80), and correlation with an established global competency scale (κ = 0.75) were high. The most difficult items were "set up and adjust EBUS equipment" and "identify vascular anatomy (EBUS)." Feedback questionnaires from trainees (response rate, 80%) and surgeons (response rate, 100%) were consistently positive regarding user friendliness, utility as an assessment tool, and educational benefit. Participants believed the tool "facilitated communicating feedback to the trainee with specific areas to work on." CONCLUSIONS: TCAT-IS is an effective tool for assessing competence in invasive staging and may enhance instruction. This initial test establishes early validity and reliability evidence, supporting the use of TCAT-IS in providing structured, specific, formative assessments of competency.

Incentive Spirometry After Lung Resection: A Randomized Controlled Trial.

BACKGROUND: Incentive spirometry (IS) is thought to reduce the incidence of postoperative pulmonary complications (PPC) after lung resection. We sought to determine whether the addition of IS to routine physiotherapy following lung resection results in a lower rate of PPC, as compared with physiotherapy alone. METHODS: A single-blind prospective randomized controlled trial was conducted in adults undergoing lung resection. Individuals with previous lung surgery or home oxygen were excluded. Participants randomized to the control arm (PHY) received routine physiotherapy alone (deep breathing, ambulation and shoulder exercises). Those randomized to the intervention arm (PHY/IS) received IS in addition to routine physiotherapy. The trial was powered to detect a 10% difference in the rate of PPC (ß = 80%). Student's t test and chi-square were utilized for continuous and categorical variables, respectively, with a significance level of p = 0.05. RESULTS: A total of 387 participants (n = 195 PHY/IS; n = 192 PHY) were randomized between 2014 and 2017. Baseline characteristics were comparable for both arms. The majority of patients underwent a pulmonary lobectomy (PHY/IS = 59.5%, PHY = 61.0%; p = 0.84), with no difference in the rates of minimally invasive and open procedures. There were no differences in the incidence of PPC at 30 days postoperatively (PHY/IS = 12.3%, PHY = 13.0%; p = 0.88). There were no differences in rates of pneumonia (PHY/IS = 4.6%, PHY = 7.8%; p = 0.21), mechanical ventilation (PHY/IS = 2.1%, PHY = 1.0%; p = 0.41), home oxygen (PHY/IS = 13.8%, PHY = 14.6%; p = 0.89), hospital length of stay (PHY/IS = 4 days, PHY = 4 days; p = 0.34), or rate of readmission to hospital (PHY/IS = 10.3%, PHY = 9.9%; p = 1.00). CONCLUSIONS: The addition of IS to routine postoperative physiotherapy does not reduce the incidence of PPC after lung resection.

Management of haemothoraces in blunt thoracic trauma: study protocol for a randomised controlled trial.

INTRODUCTION: Haemothorax following blunt thoracic trauma is a common source of morbidity and mortality. The optimal management of moderate to large haemothoraces has yet to be defined. Observational data have suggested that expectant management may be an appropriate strategy in stable patients. This study aims to compare the outcomes of patients with haemothoraces following blunt thoracic trauma treated with either chest drainage or expectant management. METHODS AND ANALYSIS: This is a single-centre, dual-arm randomised controlled trial. Patients presenting with a moderate to large sized haemothorax following blunt thoracic trauma will be assessed for eligibility. Eligible patients will then undergo an informed consent process followed by randomisation to either (1) chest drainage (tube thoracostomy) or (2) expectant management. These groups will be compared for the rate of additional thoracic interventions, major thoracic complications, length of stay and mortality. ETHICS AND DISSEMINATION: This study has been approved by the institution's research ethics board and registered with ClinicalTrials.gov. All eligible participants will provide informed consent prior to randomisation. The results of this study may provide guidance in an area where there remains significant variation between clinicians. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT03050502.

Robotic Versus Video-Assisted Thoracoscopic Lung Resection During Early Program Development.

BACKGROUND: The objective of this study is to compare robotic portal (RP) to video-assisted thoracoscopic surgery (VATS) pulmonary resections for early stage non-small cell lung cancer with respect to health care resource utilization during the first year of a robotic surgery program in thoracic oncology. METHODS: Patients who underwent anatomic lung resections using RP (n = 42) or VATS (n = 96) for early stage non-small cell lung cancer between April 2014 and March 2015 at a single institution were identified. Patient-level case costing data for hospital and home care-associated resource variables were recorded. We adopted a health care payer perspective and 30-day posthospital discharge/death time horizon. Parametric or nonparametric tests were used as appropriate and incremental cost difference using 10,000 bootstrap samples using bias-corrected and accelerated method to generate 95% confidence intervals for total cost. RESULTS: Baseline demographic and clinical characteristics were comparable between the two groups. The median total hospital cost per patient was $15,247 (95% confidence interval: $15,643 to $18,945) in the RP cohort, compared with $12,131 (95% confidence interval: $13,218 to $15,879) in the VATS cohort (n = 96; p < 0.001). Longer operating times in the RP group were the main driver of higher hospital costs. Post-hoc analysis of mean operating room time for first 20 RP procedures versus remaining 22 RP procedures found a mean difference of 71 minutes (p = 0.004), resulting in an intraoperative cost difference of $883.38 (p = 0.036). CONCLUSIONS: A micro-costing analysis demonstrates that RP pulmonary resection for early stage non-small cell lung cancer utilizes more health care resource dollars when compared with VATS during early program development, but offers similar perioperative outcomes.

Developing a National, Simulation-Based, Surgical Skills Bootcamp in General Thoracic Surgery.

BACKGROUND: The use surgical simulation across all subspecialties has gained widespread adoption in the last decade. A number of factors, including the small number of trainees, identified gaps in surgical skill training from cross-sectional surveys, increased national collaboration, and support from the national specialty committee identified a need to construct a surgical skills "bootcamp" in thoracic surgery in Canada. OBJECTIVE: The goals of the surgical skills bootcamp, as identified by the residency training program directors and the national specialty committee were to create a national, centralized, simulation-based skills workshop that focused on key foundational procedures within thoracic surgery, particularly those identified as areas of weakness by former residents; to smooth the transition to intraoperative teaching; to provide exposure to important but not necessarily universally available procedures such as advanced endoscopy; to teach non-medical expert competencies, and lastly to provide a venue for networking for residents across the country. DESIGN: The curriculum committee has constructed a 3.5 day curriculum, with a focus on hands-on skills simulation, as well as lectures, on a breadth of topics including benign esophageal disorders, lung cancer staging, minimally invasive lung surgery, crisis management and advanced bronchoscopy and endoscopy. All residents across the country attend as well as faculty from a variety of institutions. SETTING: The course is hosted centrally at the University of Toronto, Ontario over 3.5 days. A combination of auditorium and both animal and human operating room facilities are utilized. METHODS: A needs-assessment based on a formal meeting of the program directors, as well feedback from surveys identified the target areas for curriculum development. A committee of interested faculty developed the content as well as the local construct and logistics required. Iterative feedback has evolved the duration and content over the initial 3 years. RESULTS: Through formal resident feedback, national subspecialty committee review, and program director meetings the support for the bootcamp has been overwhelmingly positive. Specific resident feedback for structure, content and specific simulations has been favorable, but has also been used to modify the program. CONCLUSION: In response to identified weaknesses in training, with the support of the national specialty committee, the residency program directors, and the faculty at the University of Toronto, an intensive simulation based thoracic surgery bootcamp has successfully been created for Canadian thoracic surgery residents.

The effect of colchicine administration on postoperative pleural effusion following lung resection: a randomized blinded placebo-controlled feasibility pilot study.

OBJECTIVES: This substudy of the colchicine for prevention of perioperative atrial fibrillation (COP-AF) pilot trial seeks to assess the effect of colchicine administration on the volume of postoperative pleural drainage, duration of chest tube in situ and length of stay following lung resection. METHODS: Between April 2014 and April 2015, 100 patients undergoing lung resection at 2 tertiary care centres participated in a pilot blinded randomized trial comparing perioperative twice daily 0.6 mg of colchicine orally (n = 49) or placebo (n = 51) twice daily for 10 days. The primary outcome was total pleural drainage volume, which was recorded in 8-h intervals for the first 2 postoperative days per standardized protocol. RESULTS: Only 1 patient did not complete the trial. The mean volume of pleural drainage at 40-h mark postoperation was significantly less in the colchicine group (550.9 ml) compared with the placebo group (741.3 ml, P = 0.039). Compared with the placebo group, the colchicine group showed significantly less mean pleural drainage on postoperative Day 2 (583.8 vs 763.3 ml, P = 0.039) and beyond. There were no differences in mean time to chest tube removal (6.8 days for the colchicine group vs 5.9 days for the placebo group, P = 0.585) and mean hospital length of stay (7.4 vs 6.9 days, P = 0.641). CONCLUSIONS: Oral colchicine is potentially effective in diminishing the amount of pleural drainage following lung resection and can be considered in patients at high risk of large postoperative pleural effusion. A full-scale, prospective placebo-controlled randomized trial is needed to assess the clinical significance of perioperative colchicine administration following oncological lung resection.

Gastrointestinal Bleed from a Left Ventricle to Colonic Interposition Graft Fistula following an Esophagectomy.

Colonic interposition grafts are commonly used as an esophageal conduit following esophageal resection. Significant morbidity is associated with this reconstruction due to the nature of the operation. Many of the complications associated with this procedure have clear management strategies; however, there is a paucity of data when it comes to managing rare complications. In this report, we discuss the presentation, operative intervention, and postoperative care of a patient who presented with a left ventricle to esophageal colonic interposition graft fistula.

Development of a novel ex vivo porcine laparoscopic Heller myotomy and Nissen fundoplication training model (Toronto lap-Nissen simulator).

BACKGROUND: Surgical trainees are required to develop competency in a variety of laparoscopic operations. Developing laparoscopic technical skills can be difficult as there has been a decrease in the number of procedures performed. This study aims to develop an inexpensive and anatomically relevant model for training in laparoscopic foregut procedures. METHODS: An ex vivo, anatomic model of the human upper abdomen was developed using intact porcine esophagus, stomach, diaphragm and spleen. The Toronto lap-Nissen simulator was contained in a laparoscopic box-trainer and included an arch system to simulate the normal radial shape and tension of the diaphragm. We integrated the use of this training model as a part of our laparoscopic skills laboratory-training curriculum. Afterwards, we surveyed trainees to evaluate the observed benefit of the learning session. RESULTS: Twenty-five trainees and five faculty members completed a survey regarding the use of this model. Among the trainees, only 4 (16%) had experience with laparoscopic Heller myotomy and Nissen fundoplication. They reported that practicing with the model was a valuable use of their limited time, repeating the exercise would be of additional benefit, and that the exercise improved their ability to perform or assist in an actual case in the operating room. Significant improvements were found in the following subjective measures comparing pre- vs. post-training: (I) knowledge level (5.6 vs. 8.0, P<0.001); (II) comfort level in assisting (6.3 vs. 7.6, P<0.001); and (III) comfort level in performing as the primary surgeon (4.9 vs. 7.1, P<0.001). The trainees and faculty members agreed that this model was of adequate fidelity and was a representative simulation of actual human anatomy. CONCLUSIONS: We developed an easily reproducible training model for laparoscopic procedures. This simulator reproduces human anatomy and increases the trainees' comfort level in performing and assisting with myotomy and fundoplication.

Does the usage of digital chest drainage systems reduce pleural inflammation and volume of pleural effusion following oncologic pulmonary resection?-A prospective randomized trial.

BACKGROUND: Prolonged air leak and high-volume pleural drainage are the most common causes for delays in chest tube removal following lung resection. While digital pleural drainage systems have been successfully used in the management of post-operative air leak, their effect on pleural drainage and inflammation has not been studied before. We hypothesized that digital drainage systems (as compared to traditional analog continuous suction), using intermittent balanced suction, are associated with decreased pleural inflammation and postoperative drainage volumes, thus leading to earlier chest tube removal. METHODS: One hundred and three [103] patients were enrolled and randomized to either analog (n=50) or digital (n=53) drainage systems following oncologic lung resection. Chest tubes were removed according to standardized, pre-defined protocol. Inflammatory mediators [interleukin-1B (IL-1B), 6, 8, tumour necrosis factor-alpha (TNF-α)] in pleural fluid and serum were measured and analysed. The primary outcome of interest was the difference in total volume of postoperative fluid drainage. Secondary outcome measures included duration of chest tube in-situ, prolonged air-leak incidence, length of hospital stay and the correlation between pleural effusion formation, degree of inflammation and type of drainage system used. RESULTS: There was no significant difference in total amount of fluid drained or length of hospital stay between the two groups. A trend for shorter chest tube duration was found with the digital system when compared to the analog (P=0.055). Comparison of inflammatory mediator levels revealed no significant differences between digital and analog drainage systems. The incidence of prolonged post-operative air leak was significantly higher when using the analog system (9 versus 2 patients; P=0.025). Lobectomy was associated with longer chest tube duration (P=0.001) and increased fluid drainage when compared to sub-lobar resection (P<0.001), regardless of drainage system. CONCLUSIONS: Use of post-lung resection digital drainage does not appear to decrease pleural fluid formation, but is associated with decreased prolonged air leaks. Total pleural effusion volumes did not differ with the type of drainage system used. These findings support previously established benefits of the digital system in decreasing prolonged air leaks, but the advantages do not appear to extend to decreased pleural fluid formation.

Practice patterns in venous thromboembolism (VTE) prophylaxis in thoracic surgery: a comprehensive Canadian Delphi survey.

BACKGROUND: The incidence of venous thromboembolic events (VTE) after resection of thoracic malignancies can reach 15%, but prophylaxis guidelines are yet to be established. We aimed to survey Canadian practitioners regarding perioperative risk factors for VTE, impact of those factors on extended prophylaxis selection, type of preferred prophylaxis, and timing of initiation and duration of thromboprophylaxis. METHODS: A modified Delphi survey was undertaken over three rounds with thoracic surgeons, thoracic anesthesiologists and thrombosis experts across Canada. Participants were asked to rate each parameter on a ten-point scale. Agreement was determined a priori as an item reaching a coefficient of variation of ≤30% (0.3), with the item then discontinued from later rounds. RESULTS: In total, 72, 57 and 50 respondents participated in three consecutive rounds, respectively. Consensus was reached on previous VTE, age, cancer diagnosis, thrombophilia, poor mobilization, extended resections, and pre-operative chemotherapy as risk factors. Consensus on risk factors impacting extended prophylaxis decisions was achieved on cancer diagnosis, obesity, previous VTE and poor mobilization. With respect to perioperative prophylaxis, once daily low-molecular-weight heparin (LMWH) was the only parameter that demonstrated agreement as a common practice pattern. No agreement was achieved regarding the role of mechanical prophylaxis, unfractionated heparin (UFH) or timing of initiation of peri-operative treatment. VTE prophylaxis until discharge reached agreement but there was substantial variability regarding the role of extended prophylaxis. CONCLUSIONS: There is agreement between Canadian clinicians treating patients with thoracic malignancies regarding most risk factors for VTE, but there is no agreement on timing of initiation of prophylaxis, the agents used or factors mandating usage of extended prophylaxis.