Cancer Care Ontario's Systematic Symptom Screening Strategy: A Human-Centred Design Approach to Exploring System Gaps and Defining Strategies for the Future.

Cancer patients experience a high symptom burden throughout their illness. Quality cancer symptom management has been shown to improve patient quality of life and prevent emergency department use. Cancer Care Ontario introduced standardized symptom screening in Ontario, using the Edmonton Symptom Assessment System (ESAS) to facilitate patient reporting and management of symptoms. However, patient symptom information is not always sufficiently addressed. To address these gaps, patient and family advisors collaborated with clinicians, administrators and health system leaders from across the Province in a Symptom Management Summit to share perspectives and co-design context-specific solutions to improve care in their region.

Management of Innominate Artery Occlusion With Severe Left Common Carotid Artery Stenosis.

Innominate artery occlusion is a rare entity, particularly when coupled with severe left common carotid artery stenosis. Innominate artery disease may present with varying degrees of symptomatology and can place patients at risk for both posterior fossa and hemispheric ischemic events. We present a symptomatic case of innominate artery occlusion with severe left common carotid disease. We reviewed the literature and current options for the treatment of innominate artery disease. The patient underwent successful hybrid repair with left carotid artery retrograde stenting and left carotid artery to right carotid artery bypass. She has been symptom and re-intervention free during her one-year follow-up. We describe a successful hybrid repair of symptomatic innominate artery occlusion with concomitant severe left carotid artery stenosis in a patient with a prohibitive open thoracic surgical risk.

Source Control and Graft Preservation Using Negative Pressure Wound Therapy with Antibiotic Instillation: A Case Report.

Negative pressure wound therapy (NPWT) is widely used to treat many types of complex wounds, and the advent of the instillation and dwell time (NPWTi-d) technique has enhanced this system with the addition of automated treatment with topical solutions. In the field of vascular surgery, NPWT is utilized to help close wounds over underlying grafts; however keeping these wounds free of infection and avoiding large reoperation when infection occurs remains a challenge. In this case report we present a patient who required acute intervention for limb ischemia, with a large wound created in the groin for anastomosis of a prosthetic graft bypass. Postoperatively, the wound became infected, and the challenge became balancing infection control and graft preservation with the patient's multiple comorbidities including postoperative non-ST segment elevation myocardial infarction (NSTEMI). To avoid a large reoperation, we chose NPWTi-d with automated instillation of an antibiotic solution. There was no reinfection or return to the operating room (OR), the patient was discharged after four weeks and the wound closed on its own shortly thereafter. This case demonstrates that for high-risk surgical patients with known wound infections in the proximity of a bypass graft, NPWTi-d with antibiotic instillation may be an effective augmentation to current treatment strategies and may be considered as a stand-alone technique for wound closure in select cases.

Autoimmune pancreatitis: unveiling a hidden entity.

HYPOTHESIS: After alcohol-induced and hereditary disease, idiopathic chronic pancreatitis is the most common cause of calcifying pancreatitis. This designation is used when no associated cause of chronic pancreatitis is found. We present 6 cases of idiopathic pancreatitis in which the postoperative pathological examination results demonstrated lymphoplasmacytic sclerosing pancreatitis or autoimmune pancreatitis. DESIGN: Retrospective case series. The medical records of 6 patients referred and treated for autoimmune pancreatitis were reviewed. The duration of follow-up varies, the longest being 5 years. The disease and a literature review are reported. SETTING: A 200-bed community hospital located in a large city. The patients were referred after being treated elsewhere for recurrent pancreatitis. PATIENTS AND METHODS: Six patients with chronic recurrent pancreatitis were evaluated. They were selected because pathological review indicated that they all had autoimmune pancreatitis. RESULTS: Six cases of lymphoplasmacytic sclerosing pancreatitis are presented and suggest that lymphoplasmacytic sclerosing pancreatitis should be thought of more often in chronic autoimmune pancreatitis. CONCLUSION: Lymphoplasmacytic sclerosing pancreatitis is an increasingly recognized cause of chronic pancreatitis and should be considered in the evaluation of patients with chronic pancreatitis and no discernible cause.

Hemodynamic changes during laparoscopic gastric bypass procedures.

HYPOTHESIS: Significant detrimental intra-operative hemodynamic and respiratory changes occur in the morbidly obese during laparoscopic gastric bypass. DESIGN: Case series. SETTING: Tertiary care university hospital. PATIENTS: Thirteen patients, 10 women and 3 men, undergoing uncomplicated laparoscopic gastric bypass for morbid obesity. INTERVENTIONS: Using a pulmonary artery catheter and an arterial line, we intraoperatively monitored hemodynamic and respiratory parameters. Parameter values were recorded at set points of the procedure, and the changes were statistically analyzed. RESULTS: Significant hemodynamic and respiratory changes, mostly unfavorable, occur in the morbidly obese when creating the pneumoperitoneum in preparation for laparoscopic gastric bypass. The hemodynamic changes are attenuated when the patient is placed in the reverse Trendelenburg position and almost completely corrected when the abdomen is deflated at the completion of the procedure. The respiratory changes are more persistent. CONCLUSIONS: Laparoscopic gastric bypass surgery for morbid obesity leads to a number of predominantly detrimental, if temporary, respiratory and hemodynamic changes, which are most pronounced at the time of creation of the pneumoperitoneum. In the presence of significant cardiopulmonary comorbidities, the use of invasive intra-operative hemodynamic monitoring of the morbidly obese undergoing laparoscopic gastric bypass appears therefore justified.

A new approach in the management of chronic nonhealing leg ulcers.

Chronic leg ulcers are a major cause of mortality and morbidity. The efficacy of hyperbaric oxygen treatment is being evaluated in the management of nonhealing leg ulcers to improve skin graft survival. Twenty-seven patients with 36 chronic leg ulcers were examined. Each wound received 12 preoperative hyperbaric oxygen treatments, split-thickness skin grafting, followed by 12 postoperative hyperbaric oxygen treatments. Wound transcutaneous oxygen tension measurements (TCOM) were taken. The graft take was evaluated. At 18 months follow-up, 18 skin grafts (50%) showed complete take, 15 (41.7%) demonstrated partial take, and 3 (8.3%) failed. Hyperbaric oxygen treatment is an effective adjunct in the management of chronic leg ulcers, and its use resulted in increased graft take and survival.

Use of robotics during laparoscopic gastric bypass for morbid obesity.

To evaluate the theoretical increased precision offered by utilization of the robotic instrument, we attempted to determine whether incorporation of its use into traditional laparoscopic gastric bypass would duplicate or improve the success of the operation without increasing complications. The Roux-en-Y gastric bypass is the most commonly performed procedure for morbid obesity in the United States. We performed 120 gastric bypass procedures with traditional laparoscopy during a 30-month period. We began introducing the da Vinci Robotic Surgical System into our laparoscopic gastric bypass procedure and evaluated its effectiveness.

Laparoscopic splenectomy combined with revision of previous laparoscopic gastric bypass.

Advanced laparoscopic operations can be performed in patients who have previously undergone laparoscopic gastric bypass, because there are fewer adhesions than after open procedures. Also, revisions of previous laparoscopic gastric bypasses can be done laparoscopically for the same reasons. To demonstrate this, we present a patient who had undergone a laparoscopic gastric bypass. The operation was successful initially. After 10 months, she started to regain some of her lost weight. It was also found that she had developed idiopathic thrombocytopenia purpura, which was unresponsive to steroids. She underwent a splenectomy and revision of her gastric bypass, both done laparoscopically. This case demonstrates that these advanced laparoscopic procedures can be performed safely, even after previous surgery.

Endoscopic subfascial perforator vein surgery for patients with severe, chronic venous insufficiency.

Before 1985, surgery on incompetent perforator veins in patients with severe, chronic, venous insufficiency and venous ulcerations was generally performed utilizing long skin incisions through diseased skin and subcutaneous tissues. Known as "the Linton operation," wound infections and poor healing complicated this procedure. In 1985 G. Hauer demonstrated a new surgical technique for identifying and ligating incompetent perforator veins using an endoscopic approach in the limbs' subfascial space. This seminal contribution marked the advent of subfascial endoscopic perforator surgery (SEPS). From 1996 to 2003 our group prospectively collected data on 86 patients with chronic venous insufficiency (CVI) who underwent a SEPS procedure. Preoperative assessment consisted of color-flow duplex ultrasound scanning and ascending and descending phlebography. The patient's ages ranged from 42 to 82 years (mean 60). A total of 98 limbs underwent the SEPS procedure from the cohort group of 86 patients. The CHEAP classification of the limb disease was used: 45 limbs were classified as group C5, 53 limbs group C6. Ninety-eight SEPS procedures were performed without significant morbidity on 86 patients. Of the 53 limbs in class C6, 41 had ulcer healing within 12 weeks. The remaining 12 limbs in class C6 had ulcer healing within 6 months. In this latter group, 9 had ulcers greater than 4 cm in widest diameter. These patients underwent a split-thickness skin graft at the time the SEPS procedure was performed. The grafts have remained intact after 2 years in this cohort group. The results of this study demonstrate that the SEPS procedure incorporated into the overall treatment plan for patients with CVI produces excellent healing with minimal postoperative complications. The study also underscores the important role incompetent perforator veins have in the formation of venous ulcers.