Long-Term Voice Outcomes Following Cricotracheal Resection for Subglottic Stenosis: A Retrospective Analysis.

OBJECTIVES/HYPOTHESIS: Cricotracheal resection (CTR) is an effective treatment for refractory idiopathic subglottic stenosis (iSGS) but is associated with persistent dysphonia. Outcomes were measured longitudinally to characterize how patients' voices and self-perceived voice handicaps changed after CTR. STUDY DESIGN: Retrospective case-series. METHODS: We conducted a retrospective cohort study of patients with refractory iSGS treated by CTR from 2006 to 2017. Voice Handicap Index (VHI), Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), and acoustic analysis were prospectively collected preoperatively and postoperatively at 1, 3, 6, 12, and 24-month intervals. A linear mixed model was used to evaluate temporal change. RESULTS: Thirty-three patients (97% female) were included. VHI scores increased significantly from baseline preoperative score (27.2 ± 22.7) to a mean value of 44.3 ± 25.6 (P < .001) 1-month postoperatively but decreased below preoperative scores after 2 years (18.8 ± 11.9, P = .795). Mean fundamental frequency (F0) values in speech decreased significantly from 192.0 ± 24.9 Hz preoperatively to 167.1 ± 19.8 Hz at a 2-year follow-up (P = .002), with a nadir value at 1-month postoperatively (148.4 ± 20.5, P < .001). CAPE-V scores increased significantly from preoperative to 1-month postoperative (3.0 ± 2.3 vs. 21.9 ± 17.3, P < .001) but returned toward baseline values at 24 months after CTR (6.9 ± 4.8, P = .027). CAPE-V measurements postoperatively were correlated with VHI and F0 (Pearson coefficient = 0.54 (VHI), -0.46 (F0), P < .001). CONCLUSIONS: Following CTR, mean F0 values were significantly and consistently lower but did increase over time, correlating with patients' improving VHI and CAPE-V scores. VHI values indicate that patient's perception of their voice is not significantly impacted in long term. These results provide a framework to counsel patients about long term voice expectations. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1054-1060, 2022.

Recognition and Management of Acute and Late Complications of Pneumonectomy: Clinical Cases and Treatment.

Several important complications of pneumonectomy are discussed in a case-based format. Topics include chylothorax, cardiac herniation, postpneumonectomy syndrome, postpneumonectomy pulmonary edema, bronchopleural fistula, and empyema.

A Case Report of Acute Airway Compromise due to Subcutaneous Emphysema.

In the acute management of a trauma patient, airway patency is of utmost importance. The present case describes a male patient who presented with delayed severe upper airway obstruction secondary to massive subcutaneous emphysema following blunt traumatic injury two days previously. Airway compromise is a rarely described but serious complication of subcutaneous emphysema. Current management of subcutaneous emphysema and its association with pneumothorax is summarized. Early decompression of underlying pneumothoraces in patients with significant subcutaneous emphysema should be performed to avoid this rare complication.

A Series of Transbronchial Removal of Intracavitary Pulmonary Aspergilloma.

BACKGROUND: Intracavitary pulmonary aspergilloma is a chronic, debilitating fungal infection. Without definitive therapy, death can occur from massive hemoptysis, cachexia, or secondary infection. Although surgical resection is the standard therapy, it is not possible for many patients owing to poor pulmonary function or medical comorbidities. Aspergilloma removal through bronchoscopy is an important alternative therapy that may be available in select cases. METHODS: We retrospectively reviewed all cases referred to the University of Calgary Interventional Pulmonary Service for transbronchial removal of intracavitary aspergilloma from January 1, 2009, to January 1, 2014. RESULTS: Ten patients with intracavitary pulmonary aspergilloma were identified. In 3 patients, the aspergilloma cavity was not accessible by bronchoscopy. Successful removal of the aspergilloma with symptom improvement or resolution was achieved in 6 of 7 cases. One of the patients was lost to follow-up. Minor hypoxia lasting 12 to 72 hours was observed in 5 cases. Severe sepsis requiring an extended critical care unit stay occurred in 1 case. Follow-up ranged from 9 months to 5 years. CONCLUSIONS: Although not without risk of minor hypoxia and possible sepsis, for carefully selected patients, bronchoscopic removal of symptomatic intracavitary pulmonary aspergilloma may be an alternative therapy to surgical resection for this life-threatening disease.

A look at the thoracic surgery workforce in Canada: how demographics and scope of practice may impact future workforce needs.

BACKGROUND: The purpose of this study is to describe the demographics, training and practice characteristics of physicians performing thoracic surgery across Canada to better assess workforce needs. METHODS: We developed a questionnaire using a modified Delphi process to generate questionnaire items. The questionnaire was administered to all Canadian thoracic surgeons via email (n = 102) or mail (n = 35). RESULTS: In all, 97 surgeons completed the survey (71% response rate). The mean age of respondents was 47.7 (standard deviation 9.1) years; 10.3% were older than 60. Ninety respondents (88.7%) were men, 95 (81.1%) practised in English and 93 (76%) were born in Canada. Most (90.4%) had a medical school affiliation, with an equal proportion practising in community or university teaching hospitals. Only 18% of respondents reported working fewer than 60 hours per week, and 34% were on call more than 1 in 3. Three-quarters of work hours were devoted to clinical care, with the remaining time split among research, administration and teaching. Malignant lung disease accounted for 61.2% of practice time, with the remaining time equally split between benign and malignant thoracic diseases. Preoperative testing (49.4%) and insufficient operating time (49.5%) were the most common factors delaying delivery of care. More than 80% of respondents reported being satisfied with their careers, with 62.1% planning on retiring after age 60. CONCLUSION: This survey characterizes Canadian thoracic surgeons by providing specific demographic, satisfaction and scope of practice information. Despite challenges in obtaining adequate resources for providing timely care, job satisfaction remains high, with a balanced workforce supply and demand anticipated for the foreseeable future.

CONTEXTE: Cette étude a pour but de décrire les caractéristiques démographiques, de formation et de pratique des chirurgiens thoracique au Canada afin de mieux cerner les besoins en effectifs. MÉTHODES: Nous avons mis au point un questionnaire à l'aide d'une méthode Delphi modifiée pour générer les questions. Nous avons envoyé le questionnaire à tous les chirurgiens thoraciques canadiens par courriel (n = 102) ou par la poste (n = 35). RÉSULTANTS: En tout, 97 chirurgiens ont répondu au sondage (taux de réponse de 71 %). L'âge moyen des répondants était de 47,7 (écart-type 9,1) ans; 10,3 % avaient plus de 60 ans. Quatre-vingt-dix répondants (88,7 %) étaient des hommes, 95 (81,1 %) exerçaient en anglais et 93 (76 %) étaient nés au Canada. La plupart (90,4 %) étaient rattachés à une faculté de médecine ou, en proportion égale, exerçaient dans des centres hospitaliers communautaires ou universitaires. Seulement 18 % des répondants ont déclaré travailler moins de 60 heures par semaine et 34 % étaient « sur appel ¼ plus d'un jour sur 3. Les trois quarts des heures travaillées étaient consacrées aux soins cliniques et le temps restant se répartissait entre la recherche, les tâches administratives et l'enseignement. Le cancer du poumon a occupé 61,2 % du temps de pratique, le reste du temps se répartissant également entre diverses maladies thoraciques bénignes et malignes. Les épreuves préopératoires (49,4 %) et le manque de temps opératoire qui leur est accordé (49,5 %) figurent parmi les principaux facteurs qui retardent les chirurgies. Plus de 80 % des répondants se sont dits satisfaits de leur carrière et 62,1 % prévoient prendre leur retraite après l'âge de 60 ans. CONCLUSIONS: Ce sondage a permis de dégager les caractéristiques des chirurgiens thoraciques canadiens en fournissant des données démographiques spécifiques, leur taux de satisfaction et la portée de leur pratique. Même s'il leur est difficile d'obtenir toutes les ressources nécessaires pour prodiguer les traitements en temps opportun, leur satisfaction au travail demeure élevée et l'offre et la demande semblent équilibrées en regard des effectifs et des besoins prévus pour l'avenir prévisible.

Idiopathic subglottic stenosis: a familial predisposition.

Idiopathic subglottic stenosis is a narrowing of the trachea at the level of the cricoid cartilage of unknown etiology. It is a rare condition for which the real incidence has never been established owing to the difficulty of making the diagnosis. Although there is a female preponderance, no familial cases have been reported in the literature. We describe two pairs of sisters as well as a mother and daughter presenting with idiopathic subglottic stenosis. All known causes of tracheal stenosis were excluded, including prolonged intubation, surgery, autoimmune and inflammatory disorders, infection and gastroesophageal reflux disease. These are the first cases reported in the literature that suggest a genetic predisposition for idiopathic subglottic stenosis.

Bronchoscopic removal of a large intracavitary pulmonary aspergilloma.

Pulmonary aspergilloma is a chronic fungal infection that has a high mortality when hemoptysis occurs. Surgery is the treatment of choice, but patients often have severe physiologic impairment putting them at risk for significant surgical morbidity and mortality. We present the case of a 63-year-old woman with a large aspergilloma, unfit for surgery due to medical reasons. The aspergilloma was enlarging, with progression of the patient's symptoms of anorexia, cough, chest discomfort, and hemoptysis. Bronchoscopy revealed an airway leading into a cavity with a large fungal ball. Biopsy confirmed Aspergillus fumigatus. Using flexible and rigid bronchoscopy, the aspergilloma was mechanically removed. Eighteen months later the patient reported no hemoptysis, reduced pain and cough, significant weight gain, and improved appetite, with no recurrence of the aspergilloma on repeat imaging. To our knowledge, this is the first reported case of bronchoscopic removal of a large cavitary aspergilloma. This important new treatment modality provides a viable alternative therapy for this potentially life-threatening problem.

Automatic recognition of major fissures in human lungs.

PURPOSE: The major hurdle for three-dimensional display of lung lobes is the automatic recognition of lobar fissures, boundaries of lung lobes. Lobar fissures are difficult to recognize due to their variable shape and appearance, along with the low contrast and high noise inherent in computed tomographic (CT) images. An algorithm for recognizing the major fissures in human lungs was developed and tested. METHODS: The algorithm employs texture analysis and fissure appearance to mimic the way that surgeons/radiologists read CT images in clinical settings. The algorithm uses 3 stages to automatically find the major fissures in human lungs: (a) texture analysis, (b) fissure region analysis, and (c) fissure identification. RESULTS: The algorithm's feasibility was evaluated using isotropic CT images from 16 anonymous patients with varying pathologies. Compared with manual segmentation, the algorithm yielded mean distances of 1.92 ± 2.07 and 2.07 ± 2.37 mm, for recognizing the left and right major fissures, respectively. CONCLUSIONS: An automatic recognition algorithm for major fissures in human lungs is feasible, providing a foundation for the future development of a complete segmentation algorithm for lung lobes.

Billing, coding, and credentialing in the thoracic surgery practice.

New graduates entering thoracic surgery often face bureaucratic barriers to beginning practice. It is important to understand the credentialing and privileging process to navigate these obstacles successfully. In addition, the implementation of cutting-edge technology by recent trainees can pose problems in institutions not familiar with newer surgical techniques. Efficient coding and billing are a requirement for maintaining profitability and delivering the best care possible. This article explores theses nuances in both the American and the Canadian medical systems in building a successful practice.

Thoracic surgery associations, societies, and clubs: which organizations are right for you?

Determining which organizations to join can be challenging given the wide selection of associations, societies, and clubs available to practicing thoracic surgeons. This article briefly reviews 7 important North American thoracic surgery organizations (the American Association for Thoracic Surgery, the Canadian Association of Thoracic Surgeons, the General Thoracic Surgical Club, the Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, the Western Thoracic Surgical Association, and Women in Thoracic Surgery). The authors also review the criteria that may assist in deciding which organizations best meet a surgeon's career goals and personal expectations.

Can preoperative computed tomography of the chest predict completeness of the major pulmonary fissure at surgery?

BACKGROUND: An incomplete major pulmonary fissure can make anatomic lung resection technically more difficult and may increase the risk of complications, such as prolonged postoperative air leak. The objective of this study was to determine if preoperative computed tomography (CT) of the chest could accurately predict the completeness of the major pulmonary fissure observed at the time of surgery. METHODS: From October 2008 to June 2009, patients at a single university institution were enrolled if they underwent surgery for a pulmonary nodule, mass or known cancer. At the time of surgery, completeness of the major pulmonary fissure was graded 1 if pulmonary lobes were entirely separate, 2 if the visceral cleft was complete with an exposed pulmonary artery at the base with some parenchyma fusion, 3 if the visceral cleft was only evident for part of the fissure without a visible pulmonary artery and 4 if the fissure was absent. The preoperative CT scan of each patient was graded by a single, blinded chest radiologist using the same scale. We used the Pearson χ2 test with 2-tailed significance to test the independence of the operative and radiologic grading. RESULTS: In 48% (29 of 61) of patients, the radiologic and operative grading were the same. Of those graded differently, 94% (30 of 32) were within 1 grade. Despite this agreement, we observed no statistically significant correlation between the operative and radiologic grading (p = 0.24). CONCLUSION: The major fissure can often be well-visualized on a preoperative CT scan, but preoperative CT cannot accurately predict the completeness of the major pulmonary fissure discovered at surgery.

Do new thoracic surgeons feel ready to operate? Self-reported comfort level of thoracic surgery trainees and junior thoracic surgeons with core thoracic surgery procedures.

OBJECTIVE: To evaluate and compare self-reported surgical experience and comfort levels of Canadian thoracic surgery trainees and junior thoracic surgeons (<5 years in practice) with respect to core thoracic surgery procedures. METHODS: A modified Delphi process was used to create a survey that was distributed electronically to all Canadian thoracic surgery residents and newly graduated thoracic surgeons. A descriptive summary, including calculation of frequencies, means, proportions, and standard deviations was conducted. Associations between reported experience and comfort level for residents and surgeons were explored separately using the Pearson product moment correlation. The differences between resident and junior surgeons' rating of experience and comfort for each procedure were explored using Fisher exact tests. RESULTS: The response rates were 50% for residents and 85% for staff. Adequate or better experience was reported by residents for 9 of 18 core thoracic surgical procedures and by staff for 10 of 18 procedures. A significant difference in self-reported experience level was found between groups for only 1 of 18 procedures. Staff reported that they would confidently perform 7 of 18 procedures independently at the end of their training. The mean resident response did not reach this level of comfort for any of the 18 procedures. Eight of 16 staff had completed extra training, primarily for personal interest, whereas 4 of 6 residents were planning on further training because of job market factors. DISCUSSION: The results of this study help to characterize the comfort levels of thoracic trainees and new attending thoracic surgeons with core thoracic procedures and might assist training programs in identifying and improving areas of weakness.

Thoracic surgery training in Canada according to the residents: the thoracic surgery resident survey, of the Canadian thoracic manpower and education study (T-Med).

OBJECTIVE: The resident component of the Canadian Thoracic Manpower and Education Study (T-MED) was conducted to understand the basic demographic of Canadian thoracic surgery residents, the factors influencing their selection of training programs, current work conditions, training and competencies, and opinions in regard to the manpower needs for the specialty. DESIGN: A modified Delphi process was used to develop a survey applicable to thoracic surgery residents. In May and June 2009, residents completed the voluntary anonymous Internet-based survey. All Canadian residents participated in the survey, providing a 100% response rate. RESULTS: Most respondents were male (11/12), and the average age was 34 years old with an anticipated debt greater than $50,000 on graduation. All residents worked more than 70 hours per week, with most doing 1 : 3 or 1 : 4 on-call. Two-thirds of respondents reported being satisfied or very satisfied with their training program. Rates of anticipated competence in performing various thoracic surgeries on graduation differed between residents and program directors. Two-thirds (8/12) of residents planned to practice thoracic surgery exclusively, and hoped to practice in an academic setting. Most residents (10/12) agreed or strongly agreed that not enough jobs are available in Canada for graduating trainees and that the number of residency positions should reflect the predicted availability of jobs. CONCLUSIONS: This study has provided detailed information on thoracic surgery resident demographics and training programs. Most thoracic surgery residents are satisfied with their current training program but have concerns about their job prospects on graduation, and they believe that the number of training positions should reflect potential job opportunities. This survey represents the first attempt to characterize the current state of thoracic surgery training in Canada from the resident's perspective and may help in directing educational and manpower planning.

Weather and chinook winds in relation to spontaneous pneumothoraces.

BACKGROUND: Spontaneous pneumothorax (SP) results from the rupture of blebs or emphysematous bullae. Rapid changes in weather may precipitate this process. The city of Calgary is well suited to examine the effects of weather and specifically the rapid changes in weather associated with a chinook event and the occurrence of SP. METHODS: We performed a retrospective chart review of all cases of SP in the Calgary Health Region from 2001 to 2005. We obtained local hourly weather data over the same period from Environment Canada. We then compared the rates of SP on chinook and nonchinook days. Further, we compared mean daily temperature, humidity, wind speed and atmospheric pressure on chinook and nonchinook days. RESULTS: In all, 220 SP events from 149 patients occurred during the 4.5-year study period. There was no significant difference in the rate of SP on chinook days versus nonchinook days (p = 0.80). Similarly, there was no significant difference in the rate of SP in each of the 4 seasons (p = 0.30). We observed significantly higher average wind speed and lower mean atmospheric pressure on days with SP versus days without (p = 0.009, p = 0.020, respectively). There was no difference in mean temperature or mean relative humidity when comparing days with SP versus days without. CONCLUSION: We found no association between SP and chinook events. We observed significantly higher wind speeds and lower atmospheric pressures on days with SP versus days without.

Segmentation of lung lobes in high-resolution isotropic CT images.

Modern multislice computed tomography (CT) scanners produce isotropic CT images with a thickness of 0.6 mm. These CT images offer detailed information of lung cavities, which could be used for better surgical planning of treating lung cancer. The major challenge for developing a surgical planning system is the automatic segmentation of lung lobes by identifying the lobar fissures. This paper presents a lobe segmentation algorithm that uses a two-stage approach: 1) adaptive fissure sweeping to find fissure regions and 2) wavelet transform to identify the fissure locations and curvatures within these regions. Tested on isotropic CT image stacks from nine anonymous patients with pathological lungs, the algorithm yielded an accuracy of 76.7%-94.8% with strict evaluation criteria. In comparison, surgeons obtain an accuracy of 80% for localizing the fissure regions in clinical CT images with a thickness of 2.5-7.0 mm. As well, this paper describes a procedure for visualizing lung lobes in three dimensions using software--amira--and the segmentation algorithm. The procedure, including the segmentation, needed about 5 min for each patient. These results provide promising potential for developing an automatic algorithm to segment lung lobes for surgical planning of treating lung cancer.

Retrospective analysis of the clinical performance of anterior mediastinotomy.

BACKGROUND: Accurate staging of patients with lung cancer is imperative in generating an appropriate treatment strategy. This study examined the clinical performance of anterior mediastinotomy in staging patients with suspected left upper lobe non-small cell lung cancer. METHODS: This study was designed as a retrospective cohort. All patients with suspected left upper lobe cancer and otherwise normal computed tomography scan results were eligible. Patients with clinically unresectable disease (advanced disease or not fit for surgery) were excluded. After exclusions, 151 patients were stratified into two groups: 117 patients had cervical and anterior mediastinotomy as part of preoperative staging, and 34 had cervical mediastinoscopy only. The primary outcome was rate of preventable thoracotomy defined as thoracotomy during which either metastases to aortopulmonary or paraaortic lymph nodes, or mediastinal invasion was identified. RESULTS: The rate of preventable thoracotomy for the anterior mediastinotomy arm was 4 (3.4%) of 117, compared with 1 (2.9%) of 34 for cervical mediastinoscopy-only arm (p = 0.99). The rate of morbidity in the anterior mediastinotomy arm was 8 (6.8%) of 117, compared with 2 (5.8%) of 34 for the cervical mediastinoscopy-only arm (p = 0.99). Anterior mediastinotomy patients stayed in hospital 1 day longer (p = 0.008). Anterior mediastinotomy was successful at harvesting one or more lymph nodes in 67% of patients. Five patients (4.3%) who underwent anterior mediastinotomy were spared a thoracotomy by identification of metastases to aortopulmonary lymph nodes. CONCLUSIONS: In patients with suspected left upper lobe lung cancer and otherwise normal computed tomography scan results, anterior mediastinotomy does not significantly reduce the rate of preventable thoracotomy.

Levels of evidence and grades of recommendations in general thoracic surgery.

OBJECTIVES: To determine the grades of recommendations and levels of evidence available if the formal practice of evidence-based medicine is applied to general thoracic surgery. METHODS: Three general thoracic surgeons, by consensus, developed a sample of 10 clinically important questions. The first 3 steps of evidence-based medicine (creation of answerable clinical questions, search for best external evidence, and critical appraisal of literature) were performed. Abstracts and appropriate articles were identified through Medline from January 1999 through December 2001. A hierarchical series of search strategies was employed to identify the best level of evidence. The best evidence found was categorized according to the Oxford Centre for Evidence-Based Medicine into 4 grades of recommendations (A-D) and 5 levels of evidence (1-5). RESULTS: The best evidence found for the 10 sample questions was categorized as grade A recommendations in 5 and grade B, also in 5 questions. The levels of evidence found were la in 3 studies, 1b in 5, and 2b in 2. CONCLUSIONS: A formal evidence-based-medicine approach to general thoracic surgery found the grades of recommendation and levels of evidence for a sample of clinically important questions to be high.

Functional results and quality of life after tracheal resection for locally invasive thyroid cancer.

BACKGROUND: Local invasion of the upper aerodigestive tract by thyroid cancer, although uncommon, is a serious cause of morbidity and mortality. The impact of aerodigestive tract resection on the functional status and quality of life of the patient has not previously been investigated. METHODS: Patients with locally invasive thyroid cancer were included in a prospective surgical protocol. Swallowing function was assessed with barium swallow at 7 days and 1 month postoperatively. Postoperative quality of life (QOL) was measured using a validated head and neck QOL instrument. RESULTS: Seven patients underwent airway resection for locally invasive recurrent thyroid cancer in the period 1999 to 2001. At 1 week postoperative 3 of 7 (43%) had no evidence of aspiration on barium swallow. At 4 weeks 6 of 7 (86%) had no aspiration. Postoperative QOL scores in the domains of eating function (85.2) and emotional status (78.6) were significantly better than those of a comparison group undergoing treatment for cancers of the oropharynx, P = 0.012 and P = 0.0077, respectively. CONCLUSIONS: Tracheal resection for locally invasive thyroid cancer is associated with a return to full dietary intake within 4 weeks of surgery in most cases. Function and QOL after this type of surgery are acceptable.