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The purpose of this study was to determine the proportion of symptomatic recurrence following initial non-operative management of gallstone disease in the elderly and to test possible predictors. This is a single institution retrospective chart review of patients 65 years and older with an initial hospital visit (V1) for symptomatic gallstone disease, over a 4-year period. Patients with initial “non-operative” management were defined as those without surgery at V1 and without elective surgery at visit 2 (V2). Baseline characteristics included age, sex, Charlson comorbidity index (CCI), diagnosis, and interventions (ERCP or cholecystostomy) at V1. Outcomes assessed over 1 year were as follows: recurrence (any ER/admission visit following V1), surgery, complications, and mortality. A survival analysis using a Cox proportional hazards model was performed to assess predictors of recurrence. There were 195 patients initially treated non-operatively at V1. Mean age was 78.3 ± 7.8 years, 45.6 % were male, and the mean CCI was 2.1 ± 1.9. At V1, 54.4 % had a diagnosis of biliary colic or cholecystitis, while 45.6 % had a diagnosis of cholangitis, pancreatitis, or choledocholithiasis. 39.5 % underwent ERCP or cholecystostomy. Excluding 10 patients who died at V1, 31.3 % of patients had a recurrence over the study period. Among these, 43.5 % had emergency surgery, 34.8 % had complications, and 4.3 % died. Median time to first recurrence was 2 months (range 6 days–4.8 months). Intervention at V1 was associated with a lower probability of recurrence (HR 0.3, CI [0.14–0.65]). One-third of elderly patients will develop a recurrence following non-operative management of symptomatic biliary disease. These recurrences are associated with significant rates of emergency surgery and morbidity. Percutaneous or endoscopic therapies may decrease the risk of recurrence.

OBJECTIVES Pulmonary lobectomy is the most commonly performed surgery for lung cancer and remains the gold standard operative treatment. The reported surgical mortality from this procedure rarely differentiates between in-hospital mortality (IHM) and early post-discharge mortality (PDM). We aimed to examine the IHM and 90-day PDM over time and identify outcome predictors including patient characteristics, comorbidity and system-level factors. METHODS Data for patients who underwent lobectomy from 2005 to 2011 were acquired from a linked Ontario population-based database. Exclusions included patients undergoing sleeve lobectomy, resections for synchronous lesions, previous lung malignancy and extended length of stay (LOS) over 30 days. We reported proportional mortality and cumulative survival attributable to IHM and PDM with confidence intervals. Multivariate logistic and Cox regression analyses were performed to examine the role of variables associated with IHM and 90-day PDM. RESULTS For 5389 patients who underwent lobectomy for non-small-cell lung cancer, the median LOS was 6 (1-30) days. IHM (n = 73) was 1.4% (1.1-1.6%) and PDM (n = 101) was an additional 1.9% (1.6-2.3%) within 90 days post-lobectomy discharge. Logistic regression suggested that age [odds ratio (OR): 1.5 (1.3-1.8)], myocardial infarction [OR: 3.6 (1.8-7.0)], congestive heart failure [OR: 5.8 (2.4-13.8)], chronic obstructive pulmonary disease [OR: 1.9 (1.1-3.2)], preoperative positron emission tomography [OR: 2.7 (1.1-7.0)], peptic ulcer disease [OR: 22.1 (4.1-117.4)], hemiplegia [OR: 15.8 (1.8-141.1)], other primary cancer [OR: 0.5 (0.3-0.8)] and year of surgery [OR: 1.0 (0.8-1.0)] were potential predictors of IHM. Length of hospital stay [hazard ratio (HR): 1.1 (1.0-1.1)], male gender [HR: 1.5 (1.0-2.3)], age [HR: 1.1 (1.0-1.3)] and metastatic cancer [HR: 2.6 (1.7-4.0)] were potential predictors of PDM. CONCLUSIONS PDM represents a substantive, under-reported burden of mortality due to lobectomy. More than half of post-lobectomy mortality occurs post-discharge and the annual rate remained unchanged, while IHM decreased with time, suggesting that the improvement seen in mortality might be exclusive to the smaller IHM. Patient factors play a significant role in both IHM and PDM. We emphasize that this identifies the importance of appropriate patient selection, further investigation of risk factors and particular attention to these risk factors during regular follow-up visits to improve PDM in this high-risk patient population.

We aimed to identify risk factors for mortality after local recurrence in women treated for invasive breast cancer with breast-conserving surgery. Our prospective cohort study included 267 women who were treated with breast-conserving surgery at Women&rsquo, s College Hospital from 1987 to 1997 and who later developed local recurrence. Clinical information and tumour receptor status were abstracted from medical records and pathology reports. Patients were followed from the date of local recurrence until death or last follow-up. Survival analysis used a Cox proportional hazards model. Among the 267 women with a local recurrence, 97 (36.3%) died of breast cancer within 10 years (on average 2.6 years after the local recurrence). The actuarial risk of death was 46.1% at 10 years from recurrence. In a multivariable model, predictors of death included short time from diagnosis to recurrence [hazard ratio (hr) for 45 compared with age &le, 45 years: 0.61, 95% ci: 0.38 to 0.95, p = 0.03). The risk of death after local recurrence varies widely. Risk factors for death after local recurrence include node positivity, progesterone receptor negativity, young age at recurrence, and short time from diagnosis to recurrence.

Survivors of lung cancer surgery are among the highest-risk patients for developing another lung cancer, yet there is no clear consensus on the method of surveillance for patients after curative surgical resection. Surveillance is no longer futile because the emergence of computed tomography screening has allowed the detection of recurrences and new metachronous cancers at an early stage. In selected patients, lung cancer identified recently on routine computed tomography scan is amenable to curative treatment and is associated with longer survival.

Response by Hanna and Ferri The Editor Current Oncology June 26, 2012 We appreciate the comments and elegant statistical analysis by Dr. Cavallin and others, but we believe that they miss the forest for the trees. Our manuscript—being a retrospective review of our experience managing this complex patient population, captured in a prospective database—clearly has several statistical limitations common to studies of this type and is by no means a definitive comment on the treatment of patients with metastatic esophageal cancer. Rather, as we mentioned in the Discussion, it is to be used as hypothesis-generating fodder for a prospective randomized trial examining stenting with or without brachytherapy—an investigation that we are currently undertaking (search for {"type":"clinical-trial","attrs":{"text":"NCT01366833","term_id":"NCT01366833"}}NCT01366833 at http://clinicaltrials.gov/).

OBJECTIVE To demonstrate that senior surgical residents would benefit from focused training by professionals with management expertise. Although managerial skills are recognized as necessary for the successful establishment of a surgical practice, they are not often emphasized in traditional surgical residency curricula. DESIGN Senior residents from all surgical subspecialties at McGill University were invited to participate in a 1-day management seminar. Precourse questionnaires aimed at evaluating the residents' perceptions of their own managerial knowledge and preparedness were circulated. The seminar was then given in the form of interactive lectures and case-based discussions. The questionnaires were readministered at the end of the course, along with an evaluation form. Precourse and postcourse data were compared using the Freeman-Halton extension of the Fisher exact test to determine statistical significance (P lt; .05). SETTING McGill University Health Centre in Montreal, Quebec, Canada. PARTICIPANTS A total of 43 senior residents. RESULTS Before the course, the majority of residents (27 of 43 [63%]) thought that management instruction only happened "from time to time" in their respective programs. After the course, 15 residents (35%) felt that management topics were "well addressed," and 19 (44%) felt that management topics have been "very well addressed" (P lt; .01). Residents noted a significant improvement in their ability to perform the following skills after the course: giving feedback, delegating duties, coping with stress, effective learning, and effective teaching. On the ensemble of all managerial skills combined, 26 residents (60%) rated their performance as "good" or "excellent" after the course vs only 21 (49%) before the course (P = .02). Residents also noted a statistically significant improvement in their ability to perform the managerial duties necessary for the establishment of a surgical practice. CONCLUSIONS Surgical residency programs have the responsibility of preparing their residents for leadership and managerial roles in their future careers. An annual seminar serves as a starting point that could be built on for incorporating formal management training in surgical residency curricula.

Background: The purpose of this study was to describe Canadian general surgery residents’ perceptions regarding potential implementation of work-hour restrictions. Methods: An ethics review board–approved, Web-based survey was submitted to all Canadian general surgery residency programs between April and July 2009. Questions evaluated the perceived effects of an 80-hour work week on length of training, opera tive exposure, learning and lifestyle. We used the Fisher exact test to compare senior and junior residents’ responses. Results: Of 360 residents, 158 responded (70 seniors and 88 juniors). Among them, 79% reported working 75–100 hours per week. About 74% of seniors believed that limiting their work hours would decrease their operative exposure; 43% of juniors agreed ( p < 0.001). Both seniors and juniors thought limiting their work hours would improve their lifestyle (86% v. 96%, p = 0.12). Overall, 60% of residents did not believe limiting work hours would extend the length of their training. Regarding 24hour call, 60% of juniors thought it was hazardous to their health; 30% of seniors agreed ( p = 0.001). Both senior and junior residents thought abolishing 24-hour call would decrease their operative exposure (84% v. 70%, p = 0.21). Overall, 31% of resi dents supported abolishing 24-hour call. About 47% of residents (41% seniors, 51% juniors, p = 0.26) agreed with the adoption of the 80-hour work week. Conclusion: There is a training-level based dichotomy of opinion among general surgery residents in Canada regarding the perceived effects of work hour restrictions. Both groups have voted against abolishing 24-hour call, and neither group strongly supports the implementation of the 80-hour work week.

Background Rigid fixation is advocated as the best method to achieve good respiratory outcomes after chest wall resection at the expense of a high complication rate. The following study aims to examine the role of myocutaneous pedicled flaps, with or without soft prosthesis, in the reconstruction of small and large chest wall defects. Methods All patients who underwent resection of chest wall tumors between 2003–2010 were identified from a prospectively entered database. Operative and postoperative outcomes were documented. Patients were stratified into 2 separate groups based on the size of the residual chest wall defect; the Small Defect (SD) group ( 2 ) and the Large Defect (LD) group (>60 cm 2 ). Results Thirty-seven patients were identified over a 7-year period: 9 in the SD group and 28 in the LD group. Primary sarcoma was the most common indication for resection (57%). The mean size of the chest wall defect was 50.8 cm 2 in the SD group and 149.4 cm 2 in the LD group ( P = .001). All patients underwent reconstruction with autologous tissue, nonrigid prosthesis, or a combination of the two. Prosthesis was used in 11% of patients in the SD group and 61% of patients in the LD group ( P = .018). The rate of immediate postoperative extubation was 100% in the SD group and 89% in the LD group ( P = .42). The rate of postoperative pneumonia was 7% in the LD group vs 0% in the SD group. The rate of surgical site infection was 7% in the LD group and 0% in the SD group. A subgroup analysis of the LD group demonstrated no statistical differences in any of the measured outcomes between patients in whom mesh prosthesis was used and patients in whom a myocutaneous flap alone was used. However, there was a clinical suggestion of prolonged ventilation in the subgroup where mesh was not used and of higher infection rates in the subgroup where mesh was used. Conclusion Small chest wall defects can be reconstructed with pedicled myocutaneous flaps alone without compromising respiratory outcomes. In carefully selected patients with moderate size defects larger than 60cm 2 , reconstruction with pedicled myocutaneous flap alone offers similar postoperative outcomes as reconstruction with nonrigid prosthesis, at the expense of a possible need for a short period of mechanical ventilation.

This study aimed to describe the differences in the management of symptomatic gallstone disease within different elderly groups and to evaluate the association between older age and surgical treatment. This single-institution retrospective chart review included all patients 65 years old and older with an initial hospital visit for symptomatic gallstone disease between 2004 and 2008. The patients were stratified into three age groups: group 1 (age, 65–74 years), group 2 (age, 75–84 years), and group 3 (age, ≥ 85 years). Patient characteristics and presentation at the initial hospital visit were described as well as the surgical and other nonoperative interventions occurring over a 1-year follow-up period. Logistic regression was performed to assess the effect of age on surgery. Data from 397 patient charts were assessed: 182 in group 1, 160 in group 2, and 55 in group 3. Cholecystitis was the most common diagnosis in groups 1 and 2, whereas cholangitis was the most common diagnosis in group 3. Elective admissions to a surgical ward were most common in group 1, whereas urgent admissions to a medical ward were most common in group 3. Elective surgery was performed at the first visit for 50.6% of group 1, for 25.6% of group 2, and for 12.7% of group 3, with a 1-year cumulative incidence of surgery of 87.4% in group 1, 63.5% in group 2, and 22.1% in group 3. Inversely, cholecystostomy and endoscopic retrograde cholangiopancreatography (ERCP) were used more often in the older groups. Increased age (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.84–0.91) and the Charlson Comorbidity Index (OR, 0.80; 95% CI, 0.69–0.94) were significantly associated with a decreased probability of undergoing surgery within 1 year after the initial visit. Even in the elderly population, older patients presented more frequently with severe disease and underwent more conservative treatment strategies. Older age was independently associated with a lower likelihood of surgery.

Acute diaphragmatic hernia is a result of diaphragmatic injury that accompanies severe blunt or penetrating thoracoabdominal trauma. It is frequently diagnosed early on the trauma bay chest radiograph or CT scan of the chest. However, in the absence of a hernia, it may be difficult to identify traumatic diaphragmatic injury on conventional imaging. A midline laparotomy is the advocated approach for repair of acute diaphragmatic trauma because it offers the possibility of diagnosing and repairing frequently associated intraabdominal injuries. In hemodynamically stable patients with penetrating left thoracoabdominal trauma, the incidence of injury to the diaphragm is very high, and thoracoscopy or laparoscopy is recommended for the diagnosis and repair of a missed diaphragmatic injury. Repair with nonabsorbable simple sutures is adequate in most cases, and the use of mesh should be reserved for chronic and large defects. Outcomes of acute diaphragmatic hernia repair are largely dictated by the severity of concomitant injuries, with the Injury Severity Score being the most widely recognized predictor of mortality.

The clinical diagnosis of primary thyroid cancer is uncommon, constituting 1.5% of all cancers in the United States. Clinically diagnosed metastatic cancer to the thyroid gland is rare. Colon cancer is one of the most common cancers in the United States, with a high propensity to metastasize; 30% to 40% of patients have metastatic disease at the initial diagnosis. The most common sites of metastasis from colon cancer are the regional lymph nodes, the liver, the lung, and the peritoneum. Colon cancer metastasis to the thyroid gland is rare, with only a few reported cases, mainly in the pathology literature. These cases describe metastasis from colon cancer to the thyroid gland that became apparent years after the initial diagnosis of colon cancer and were usually associated with dissemination to the liver, the lung, or both. We report a case of colonic adenocarcinoma metastatic to the thyroid gland and lung without involvement of the liver. A review of the literature is also included.

Stereotactic breast biopsy techniques minimize the surgical trauma associated with conventional wire-guided open breast biopsy for non-palpable breast lesions (NPBLs). Advanced breast biopsy instrumentation (ABBI) allows for a 2-cm core of breast tissue to be excised under stereotactic guidance in an outpatient setting. We report our initial experience with ABBI. Hospital charts from 89 ABBI procedures between 10/1996 and 07/2002 were retrospectively reviewed for patient characteristics, ABBI parameters, radiographic appearance, pathology, complications, and clinical follow-up. Data are presented as percentage/median (range). Median age was 59 years (range: 39-80 years), mammographic lesions were classified as calcifications 49% (44/89), soft tissue 39% (35/89), or mixed 11% (10/89). Median radiographic size was 7 mm (1-60 mm). Final pathology revealed ductal carcinoma in situ (DCIS) in 7% (6/89) and invasive cancer in 22% (20/89). Microscopically clear margins were obtained in 55% (11/20) of patients with invasive cancer. Of these, 82% (9/11) chose not to undergo further local surgical therapy. Eight patients remain disease free at 56 months (range: 41-95 months) follow-up. The ninth patient was deceased at 6 months from an unrelated cause. The overall complication rate was 3% (3/89). A definitive diagnosis was obtained in 100% of malignant and 87% of benign cases. Median waiting time was 19 days (range: 0-90 days). Our experience demonstrates that ABBI is an effective diagnostic tool for NPBLs. It is associated with minimal complications, and provides negative margins in over half of malignant cases. In selected patients with invasive cancer and negative margins, ABBI may obviate the need for further local surgical treatment. ABBI merits additional investigation as a therapeutic modality for early breast cancer.

s 22nd European Conference on General Thoracic Surgery June 15-18, 2014, Copenhagen, Denmark

OBJECTIVES: Pulmonary lobectomy is the most commonly performed surgery for lung cancer and remains the gold standard operative treatment. The reported surgical mortality from this procedure rarely differentiates between in-hospital mortality (IHM) and early postdischarge mortality (PDM). We aimed to examine the IHM and 90-day PDM over time and identify outcome predictors including patient characteristics, comorbidity and system-level factors. METHODS: Data for patients who underwent lobectomy from 2005 to 2011 were acquired from a linked Ontario population-based database. Exclusions included patients undergoing sleeve lobectomy, resections for synchronous lesions, previous lung malignancy and extended length of stay (LOS) over 30 days. We reported proportional mortality and cumulative survival attributable to IHM and PDM with confidence intervals. Multivariate logistic and Cox regression analyses were performed to examine the role of variables associated with IHM and 90-day PDM. RESULTS: For 5389 patients who underwent lobectomy for non-small-cell lung cancer, the median LOS was 6 (1–30) days. IHM (n = 73) was 1.4% (1.1–1.6%) and PDM (n = 101) was an additional 1.9% (1.6–2.3%) within 90 days post-lobectomy discharge. Logistic regression suggested that age [odds ratio (OR): 1.5 (1.3–1.8)], myocardial infarction [OR: 3.6 (1.8–7.0)], congestive heart failure [OR: 5.8 (2.4–13.8)], chronic obstructive pulmonary disease [OR: 1.9 (1.1–3.2)], preoperative positron emission tomography [OR: 2.7 (1.1–7.0)], peptic ulcer disease [OR: 22.1 (4.1–117.4)], hemiplegia [OR: 15.8 (1.8–141.1)], other primary cancer [OR: 0.5 (0.3–0.8)] and year of surgery [OR: 1.0 (0.8– 1.0)] were potential predictors of IHM. Length of hospital stay [hazard ratio (HR): 1.1 (1.0–1.1)], male gender [HR: 1.5 (1.0–2.3)], age [HR: 1.1 (1.0–1.3)] and metastatic cancer [HR: 2.6 (1.7–4.0)] were potential predictors of PDM. CONCLUSIONS: PDM represents a substantive, under-reported burden of mortality due to lobectomy. More than half of post-lobectomy mortality occurs post-discharge and the annual rate remained unchanged, while IHM decreased with time, suggesting that the improvement seen in mortality might be exclusive to the smaller IHM. Patient factors play a significant role in both IHM and PDM. We emphasize that this identifies the importance of appropriate patient selection, further investigation of risk factors and particular attention to these risk factors during regular follow-up visits to improve PDM in this high-risk patient population.

s 22nd European Conference on General Thoracic Surgery June 15-18, 2014, Copenhagen, Denmark Session X: Pulmonary Neoplastic II TUESDAY, 17 JUNE 2014 11:00 12:30

The main goal of treating ductal carcinoma in situ (dcis) is to prevent the development of invasive breast cancer. Most women are treated with breast-conserving surgery (bcs) and radiotherapy. Age at diagnosis may be a risk factor for recurrence, leading to concerns that additional treatment may be necessary for younger women. We report a population-based study of women with dcis treated with bcs and radiotherapy and an evaluation of the effect of age on local recurrence (lr). All women diagnosed with dcis in Ontario from 1994 to 2003 were identified. Treatments and outcomes were collected through administrative databases and validated by chart review. Women treated with bcs and radiotherapy were included. Survival analyses were performed to evaluate the effect of age on outcomes. We identified 5752 cases of dcis, 1607 women received bcs and radiotherapy. The median follow-up was 10.0 years. The 10-year cumulative lr rate was 27% for women younger than 45 years, 14% for women 45&ndash, 50 years, and 11% for women more than 50 years of age (p < 0.0001). The 10-year cumulative invasive lr rate was 22% for women younger than 45 years, 10% for women 45&ndash, 50 years, and 7% for women more than 50 years of age (p < 0.0001). On multivariate analyses, young age (, 95% confidence interval (ci): 1.9 to 3.7, p < 0.0001, hr for invasive lr: 3.0, 95% ci: 2.0 to 4.4, p < 0.0001]. An age of 45&ndash, 50 years was also significantly associated with invasive lr (hr: 1.6, 95% ci: 1.0 to 2.4, p = 0.04). Age at diagnosis is a strong predictor of lr in women with dcis after treatment with bcs and radiotherapy.

We appreciate the comments by Yamamoto et al. [1] regarding our recent article [2]. We understand the questions regarding our statistical methods with respect to the propensity matching, but in our opinion, the methods used were appropriate in addressing the question of whether video assisted thoracic surgery (VATS) lobectomy is oncologically equivalent to open lobectomy with respect to overall and disease-free survival. By using propensity score matching (PSM), we attempted to reduce the bias due to confounding variables that could be found in an estimate of the open vs VATS lobectomy effect obtained from simply comparing overall survival outcomes among subjects [3]. It is well known that in observational studies, the treatment group often exhibits imbalance on covariates. This imbalance will also be confounded with treatment, and it is difficult to attribute differences in main outcome to the treatment, as the covariates are also believed to influence the outcome. Inability to balance confounders through some mechanism, will show that the treatment groups are not sufficiently overlapping with respect to these confounders and that selection bias may not be resolvable. Therefore, our use of PSM was an attempt to mimic randomization by creating a sample of patients who had open lobectomy, which is comparable onmost available covariates to a sample of subjects who had VATS lobectomy. In particular, in our study we were interested in matching patients who were similar except for the operative approach so that we could compare the lung cancer survival for each approach. Among the five covariates we used, histology was known preoperatively because of a preoperative biopsy. We used pathological stages as we were interested in survival, and pathological stage is more accurate than clinical stage. For example, a patient may be clinical T1 N0 but pathological stage T1 N1 or T1 N2, which would give them a significantly different prognosis. Shadish et al. [4] argue that PSM requires large samples, overlap between treatment and control groups must be substantial, and hidden bias may remain after matching, because the procedure only controls for observed variables (to the extent that they are perfectly measured), to be more accurate, as one of the disadvantages. Hence, our work was focused on investigating any difference in survival outcome after balancing the impact of the covariates including pathological T and N, which was known to predict oncological prognosis. The other point mentioned as an option was the use of simple multivariable analysis as adjustment. We agree that one can proceed in that direction if the research question directs to that. However, in our case, as our research interest was to see the impact of operative approach, it was advantageous to have patients comparable in most aspects. Liem et al. [5] further explained the advantages of propensity score-stratified vs traditional multivariable-adjusted modelling. One of the advantages of the PSM model is that it does not need to be parsimonious and is easy to understand because it is not the focus of the study other than balancing the covariates included in the model. In conclusion, we believe that PSM allowed us to compare two groups of patients who were essentially identical in terms of key variables that are known to affect survival after lung cancer surgery with the exception of the operative approach. If clinical staging had been used rather than pathological staging, we would have undoubtedly compared apples and oranges. Thus, the only significant difference between the two groups of patients in our study that may have influenced their overall and disease-free survivals was whether their lung cancer was resected by open lobectomy or VATS lobectomy. A propensity-matched analysis is therefore appropriate for minimizing selection bias and allowing us to compare two very similar groups. Although a randomized study would be ideal to address this question, lack of equipoise on the part of the public and surgeons likely precludes completion of such a study.

We would like to thank Dr Baisi et al. [1] for their insightful comments on our paper, specifically regarding the discrepancy in cancer-specific survival between matched patients who underwent lung cancer resection via VATS lobectomy vs open lobectomy [2]. Although no statistical difference could be detected in cancer-specific survival, the survival curves seem to show a slight divergence in favour of open lobectomy. This apparent divergence can be explained by two potential theories. The first is that it is due to chance. One will always wonder whether a significant difference may have been detected if a larger population sample was available, and whether a study with enough power can be actually achieved. The second theory is that better cancer-specific survival can be attributed to better lymph node dissection in the open group. Although we did not find a difference in the number of lymph nodes harvested between the two groups, larger database studies have clearly demonstrated that the rates of N1 lymph node harvest in VATS lobectomy is inferior to open lobectomy [3]. Speculation remains around whether better lymph node harvesting translates into better survival. We agree with Dr Baisi et al. [1] in restricting our conclusions to early-stage lung cancer. Although other groups have demonstrated the feasibility of VATS resection for large or locally advanced tumours [4], our data include only Stage I and II patients, with a predominance of Stage I disease. We are grateful to Dr Baisi et al. [1] for their kind and insightful comments, and we thank them for taking the time to remark on our work.