Search

Background: Asymptomatic congenital pulmonary airway malformations (CPAMs) and congenital lobar emphysema (CLE) may safely be observed, though little is known about how many patients later require surgery. The management of these lesions remains controversial, as limited research exists on which patients later require surgery. Notably, there are few reported cases where patients become symptomatic and require definitive treatment beyond childhood., Case Description: We present the rare case of a 17-year-old female who developed dyspnea on exertion associated with pre-syncope, following diagnosis of a CPAM at birth. She had undergone surveillance until 2 years of age. The decision to proceed with a left upper lobectomy via thoracotomy was made, for treatment of her symptoms. During the surgery, one lung ventilation suggested that oxygenation had likely limited to the patient's healthy lung, prior to intervention. The surgery was uncomplicated, and her recovery was uneventful. Pathology revealed CLE., Conclusions: This case highlights that congenital lung malformations should remain in the differential diagnosis of patients presenting in adolescence or adulthood with new onset respiratory symptoms. For patients with a history of untreated congenital lung pathology, it is important to consider the presence of adhesions and loss of domain in perioperative planning. This case also highlights the ongoing need for research on the prognostication of these lesions to better inform surveillance., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-28/coif). D.G.F. reports that he has been the facilitator of a physician advisory meeting for AstraZeneca. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Objective: This study evaluated the relationship between medical student Grit and thoracic surgery career interest., Design: An online questionnaire was designed to measure self-reported ratings of Grit among medical student using the Short-Grit scale, as well as thoracic surgery career interest., Setting: Faculty of Medicine, Dalhousie University, Halifax, NS, Canada., Participants: From 2019 to 2021, 192/367 (52.3%) participants in their first or second year of medical school. The cohort was comprised of 109 (56.8%) females while 115 (59.9%) were <24 years of age., Results: Mean Grit was high (M = 4.159 +/- 0.450) among medical students. There were 80 (41.2%) students interested in thoracic surgery. There was a significant difference in Grit between students with a career interest in thoracic surgery (4.256 +/- 0.442) and those uninterested in thoracic surgery (4.089 +/- 0.444); t(190) = 2.572, p = 0.011; Cohen's D = 0.442. Career interest in thoracic surgery was not influenced by career factor interest., Conclusions: Grittier students have a career interest in thoracic surgery. Recruitment teams in thoracic surgery residency programs with high rates of burnout and poor psychological wellbeing among trainees may take interest in these findings., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: We describe a novel process using positive deviance (PD) with the Canadian Association of Thoracic Surgeons members, to identify perioperative best practice to minimise anastomotic leak (AL) and length of stay (LOS) following oesophagectomy. To our knowledge, this is the first National combination of level 1 evidence with expert opinion (ie, PD seminar) aimed at reducing AL and LOS in oesophageal surgery. Our primary hypothesis is that a multicentre National PD seminar is feasible, and could lead to the generation of best practices recommendations aimed at reducing AL and LOS in patients with oesophageal cancer., Methods: Adverse events, LOS and AL incidence/severity following oesophagectomy were prospectively collected from seven Canadian thoracic institutions using Thoracic Morbidity and Mortality classification system (2017-2020). Anonymised display of centre's data were presented, with identification of centres demonstrating PD. Surgeons from PD sites discussed principles of care, culminating in the consensus recommendations, anonymously rated by all (5-point Likert scale)., Results: Data from 795 esophagectomies were included, with 25 surgeons participating. Two centres were identified as having the lowest AL rates 44/395 (11.1%) (vs five centres 71/400 (17.8%) (p<0.01)) and shortest LOS 8 days 45 (IQR: 6-14) (vs 10 days (IQR: 8-18) (p<0.001)). Recommendations included preoperative (prehabilitation, smoking cessation, chemotherapy for patients with dysphagia, minimise stents/feeding tubes), intraoperative (narrow gastric conduit, intrathoracic anastomosis, avoid routine jejunostomy, use small diameter closed-suction drains), postoperative day (POD) (early (POD 2-3) enteral feeding initiation, avoid routine barium swallow studies, early removal of tubes/drains (POD 2-3)). All ranked above 80% (4/5) in agreement to implement recommendations into their practice., Conclusion: We report the feasibility of a National multicentre PD seminar with the generation of best practice recommendations aimed at reducing AL and LOS following oesophagectomy. Further research is required to demonstrate whether National PD seminars can be an effective quality improvement tool., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The SCREEN study investigated screening eligibility and survival outcomes between heavy smokers and light-or-never-smokers with lung cancer to determine whether expanded risk factor analysis is needed to refine screening criteria. SCREEN is a retrospective study of 917 lung cancer patients diagnosed between 2005 and 2018 in Nova Scotia, Canada. Screening eligibility was determined using the National Lung Screening Trial (NSLT) criteria. Mortality risk between heavy smokers and light-or-never-smokers was compared using proportional-hazards models. The median follow-up was 2.9 years. The cohort was comprised of 179 (46.1%) female heavy smokers and 306 (57.8%) female light-or-never-smokers. Light-or-never-smokers were more likely to have a diagnosis of adenocarcinoma [n=378 (71.6%)] compared to heavy smokers [n=234 (60.5%); P< 0.001]. Heavy smokers were more frequently diagnosed with squamous cell carcinoma [n=111 (28.7%)] compared to light-or-never-smokers, [n=100 (18.9%); P< 0.001]. Overall, 36.9% (338) of patients met NLST screening criteria. There was no difference in 5-year survival between light-or-never-smokers and heavy smokers [55.2% (338) vs 58.5% (529); P = 0.408; HR 1.06, 95% CI 0.80-1.40; P = 0.704]. Multivariate analysis showed that males had an increased mortality risk [HR 2.00 (95% CI 1.57-2.54); P< 0.001]. Half of lung cancer patients were missed with the conventional screening criteria. There were more curable, stage 1 tumors among light-or-never-smokers. Smoking status and age alone may be insufficient predictors of lung cancer risk and prognosis. Expanded risk factor analysis is needed to refine lung cancer screening criteria., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Postoperative adverse events (AEs) following pulmonary resection enormously impact patient well-being, length of stay (LOS) and healthcare costs. Standardised AE data collection can be used to identify positive outliers demonstrating positive deviance (PD) who may be helpful to inform the best practice. Here, we describe our initial experience of a novel quality improvement process using PD to reduce LOS and AEs., Methods: AE rates and LOS were collected from four centres (2014-2020) using a common dictionary. Surgeons repeatedly participated in 60 to 90 min seminars consisting of the following process: identify outcome and procedure targeted, review relevant best evidence literature, view all data anonymised by surgeon or centre (if multicentre), choose and reveal identity of best performance PD outliers, who discuss their management principles while all receive self-evaluation reports, followed by collegial discussion to generate consensus recommendations, voted by all. We assessed overall impact on AEs and LOS using aggregate data in a before/after analysis., Results: A total of 131 surgeons (average 12/seminar) participated in 11 PD seminars (8 local and 3 multicentre), yielding 85 consensus recommendation (average 8/seminar). Median LOS following lobectomy decreased from 4.0 to 3.0 days (p=0.04) following local PD seminars and from 4.0 to 3.5 days (p=0.11) following multicentre seminars. Trends for reductions in multiple AE rates were also observed., Conclusion: While limited by the longitudinal design, these findings provide preliminary support for this data-driven, collegial and actionable quality improvement process to help standardise and improve patient care, and merits further more rigorous investigation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To describe our experience using transthoracic ventilation to facilitate oral endotracheal tube (ETT) exchange after accidental ETT cuff rupture during a case of congenital tracheoesophageal fistula (TEF) repair., Clinical Features: A 53-yr-old male underwent a congenital H-type TEF repair via right-sided thoracotomy with a single-lumen ETT and a bronchial blocker. A large air leak developed after ETT cuff rupture during fistula closure. Transthoracic intubation via tracheotomy was performed to continue ventilation during an oral ETT exchange in the lateral position. No hypoxia or hemodynamic compromise occurred., Conclusions: Airway device choice for TEF repair must be carefully considered in conjunction with the surgical team. In the present case of accidental ETT cuff rupture, rescue transthoracic ventilation safely facilitated oral ETT exchange., (© 2022. Canadian Anesthesiologists' Society.)

Air leaks are the most common complication after pulmonary resection. Enhanced recovery after surgery (ERAS) programs must be designed to manage parenchymal air leaks. ERAS programs should consider two components when creating protocols for air leaks: assessment and management. Accurate assessment of air leaks using traditional analogues devices, newer digital drainage systems, portable devices and chest X-rays (CXR) are reviewed. Published data suggests that digital drainage systems result in a more confident assessment of air leaks. The literature regarding the management of postoperative air leaks, including the number of chest tubes, the role of applied external suction, invasive maneuvers and discharge with a portable device is reviewed. The key findings are that a single chest drain is adequate in the majority of cases to manage an air leak, the use of applied external suction is unlikely to prevent or prolong an air leak, autologous blood patch pleurodesis may potentially shorten postoperative air leaks and there is sufficient data to support that patients can safely be discharged with a portable drainage system. There is also literature to support the design of protocols for management of postoperative air leaks. Standardization of postoperative care through ERAS programs will allow for the design of larger RCTs to better understand some of the controversies around the management of postoperative air leaks., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Evidence for ERAS within thoracic surgery (ERATS) is building. The key to enabling early recovery and ambulation is ensuring that postoperative pain is well controlled. Surgery on the chest is considered to be one of the most painful of surgical procedures for both open and minimally invasive surgery (MIS) approaches. Increasing use of MIS and improved perioperative care pathways has resulted in shorter length of stay (LOS), requiring patients to achieve optimal pain control earlier and meet discharge criteria sooner, sometimes on the same day as surgery. This requires optimizing pain control earlier in the postoperative recovery phase in order to enable ambulation and a better recovery profile, as well as to minimize the risk for development of chronic persistent postoperative pain (CPPP). This review will focus on the options for pain management protocols within an ERAS program for thoracic surgery patients (ERATS)., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Single port thoracoscopy is an approach aimed at minimizing trauma to the chest wall during lung resection. The objectives of this study were to describe early experience in the transition from multiple port video-assisted thoracic surgery (VATS) to single port surgery (S-VATS) and to compare perioperative outcomes between approaches., Methods: Consecutive anatomic lung resections using S-VATS were reviewed and compared to a historical, prospective cohort of multiple port VATS cases. Outcomes analysis was focused on the use of operating room resources and postoperative recovery., Results: Over 12 months, 50 S-VATS procedures were completed by one surgeon and compared to an equal number of VATS patients. The groups were similar in age, gender, BMI, comorbidity, tumor size and pulmonary function. There was no statistically significant difference in operative time. All tumors were completely resected (R0) and the median number of lymph nodes evaluated pathologically was equivalent {S-VATS=7 [4-10]; VATS=7 [4-10]; P=0.92}. There was no significant difference in conversion rate {S-VATS=2 (4%); VATS=1 (2%); P=0.56}. The median length of stay was similar in both groups {S-VATS=4 [3-7]; VATS=4 [3-7]; P=0.99}. There was no mortality and no significant difference in the rate of major complications {S-VATS=10/50 [20%]; VATS=5/50 [10%]; P=0.26}. There was no difference in patient reported pain as measured by a visual analog scale at 24 hours {S-VATS=4 [2-5]; VATS=4 [3-5]; P=0.63}., Conclusions: Early experience in the transition from multiple port VATS to S-VATS lung resection indicates that safety, efficiency and surgical quality are preserved. More long-term data are required. Alternative approaches to perform thoracoscopic lung resection should be carefully evaluated and compared to established minimally invasive techniques.

Postoperative clinical pathways have been shown to improve postoperative care and decrease length of stay in hospital. In thoracic surgery there is a need to develop chest tube management pathways. This paper considers four aspects of chest tube management: (I) appraising the role of chest X-rays in the management of lung resection patients with chest drains; (II) selecting of a fluid output threshold below which chest tubes can be removed safely; (III) deciding whether suction should be applied to chest tubes; (IV) and selecting the safest method for chest tube removal. There is evidence that routine use of chest X-rays does not influence the management of chest tubes. There is a lack of consensus on the highest fluid output threshold below which chest tubes can be safely removed. The optimal use of negative intra-pleural pressure has not yet been established despite multiple randomized controlled trials and meta-analyses. When attempting to improve efficiency in the management of chest tubes, evidence in support of drain removal without a trial of water seal should be considered. Inconsistencies in the interpretation of air leaks and in chest tube management are likely contributors to the conflicting results found in the literature. New digital pleural drainage systems, which provide a more objective air leak assessment and can record air leak trend over time, will likely contribute to the development of new evidence-based guidelines. Technology should be combined with continued efforts to standardize care, create clinical pathways, and analyze their impact on postoperative outcomes.

Background: Transabdominal ultrasonography (TAUS) is the most commonly used modality to diagnose gallbladder (GB) disease. GB polyps are reported in 1-5.6 % of TAUS studies. Histopathologic studies suggest that there is a relationship between GB polyps and GB cancer. Previous literature suggests GB polyps reported on TAUS do not correlate well with histological findings. There have been recent advances in TAUS technology. We hypothesize the recent advances in TAUS technology have improved the accuracy of TAUS for diagnosing GB polyps., Methods: Radiology and pathology databases at our tertiary care center were retrospectively searched between January 1, 2000, and December 31, 2010. Ultrasound reports that suggested a GB polyp was present on TAUS were correlated to histopathology in cases where a cholecystectomy was performed. The pathology reports where a GB polyp was found were correlated with preoperative TAUS reports., Results: There were 102,740 TAUS reports referring to the GB, of which 6,612 (6.4 %) contained search terms suggesting a GB polyp was present. There were 13,278 cholecystectomy pathology reports, of which 159 (1.2 %) included a diagnosis of GB polyp. TAUS detected only 50 % of the polyps identified on histopathology. The sensitivity and specificity of TAUS for diagnosing GB polyps were 50.0 and 98.3 %, respectively. The positive and negative predictive values were 10.5 and 99.8 %., Conclusions: Despite improvement in TAUS technology, the accuracy for GB polyps remains poor. This needs to be considered when managing patients with TAUS-detected GB polyps. We recommend that the decision to operate on TAUS-detected GB polyps be largely based on symptoms, and following GB polyps with TAUS should be discouraged.

Following the attack of September 11, 2001, as senior leaders in the reserves, we had to shift our focus from everyday civilian issues to our duties and responsibilities as military officers. These events led to an examination of the implications for civilian organizations of nurses serving as military reservists. In this article we address the personal and civilian employer impact of military reserve service during a national emergency and policy implications for administrators. Recommendations for preparing for organizational loss of reservists in key administrative and leadership positions and providing support for reservists while implementing a plan for a potential reserve call-up are suggested.

Primary care providers are faced with numerous challenges when prescribing drugs for elderly patients. Multiple drug use, coexisting illness, and normal physiologic changes associated with aging place older persons at increased risk for adverse drug reactions (ADRs). Sample selection bias in drug clinical trials and inappropriate prescribing of contraindicated drugs contribute to the risk profile. Because multiple drug use and ADRs are relatively common in the elderly, special caution should be used when prescribing for this population. The primary care provider should have a good understanding of the factors that put the elderly at increased risk for ADR, the classes of drugs inappropriate for elderly patients, the physiologic changes of aging that may produce an altered pharmacologic response, and the issues associated with adherence to drug therapy. This article identifies factors that contribute to ADRs in the elderly and proposes strategies to reduce or avoid risk. Identifying and preventing ADRs in older Americans is a Healthy People 2000 health protection goal, perhaps more important given projected demographics over the next 20 to 30 years.

In the time that has passed since our evaluation, 14 of the 16 recommendations we made have been addressed by the education staff and incorporated into the program. Program monitoring methods have been implemented and patient follow-up has been improved. After the recommendations were incorporated into the program, a final but noteworthy outcome of the evaluation process was achieved. Formal recognition as a model diabetes patient education program was given by the state of Ohio Diabetes Control Program. Systematic evaluation of a patient education program may seem an overwhelming and impossible task to accomplish, but with some creative brainstorming with staff it can be done. And the payoffs are worth the effort.