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Growing, small, peripheral, pulmonary nodules in patients at high risk for lung cancer lead to requests for video-assisted thoracoscopic (VATS) resection for pathologic diagnosis. The purpose of this randomized controlled trial was to determine if preoperative localization using percutaneously placed computed tomography (CT)-guided platinum microcoils decreases the need for thoracotomy or VATS anatomic resection (segmentectomy/lobectomy) for diagnosis.Patients with undiagnosed nodules of 15 mm or less were randomized to either no localization or preoperative microcoil localization. Coils were placed with the distal end deep to the nodule and the superficial end coiled on the visceral pleural surface with subsequent visualization by intraoperative fluoroscopy and VATS. Nodules were removed by VATS wedge excision using endostaplers. The primary outcome was a VATS wedge excision for pathologic diagnosis of the nodule without the need for either thoracotomy or VATS anatomic resection.Sixty patients were randomized and 56 underwent surgery between March 2010 and June 2012. Twenty-nine underwent microcoil localization and 27 did not. The baseline characteristics (age, sex, forced expiratory volume in the first second of expiration, nodule size/depth) were similar. The coil group had a higher rate of successful diagnosis with VATS wedge resection alone (27/29 vs 13/27; P .001), decreased operative time to nodule excision (37 ± 39 vs 100 ± 67 minutes; P .001), and reduced stapler firings (3.7 ± 2.0 vs 5.9 ± 31; P = .003) with no difference in total costs. Pathologic diagnoses included 14 benign nodules, 32 primary lung malignancies, and 10 metastases. There were no clinically significant complications related to the coil placement or wedge resection.Preoperative CT-guided microcoil localization decreases the need for thoracotomy or VATS anatomic resection for the diagnosis of small peripheral pulmonary nodules.

Aim: To develop a video-based educational tool designed for teaching thoracic anatomy and to examine whether this tool would increase students' stimulation and motivation for learning anatomy. Methods: Our video-based tool was developed by recording different thoracoscopic procedures focusing on intraoperative live thoracic anatomy. The tool was then integrated into a pre-existing program for first year medical students (n = 150), and included cadaver dissection of the thorax and review of clinical problem scenarios of the respiratory system. Students were guided through a viewing of the videotape that demonstrated live anatomy of the thorax (15 minutes) and then asked to complete a 5-point Likert-type questionnaire assessing the video's usefulness. Apart from this, a small group of entirely different set of students was divided into two groups, one group to view the 15-minute video presentation of thoracoscopy and chest anatomy and the other group to attend a 15-minute lecture of chest anatomy using radiological images. Both groups took a 10-item pretest and post-test multiple choice questions examination to assess short-term knowledge gained. Results: Of 150 medical students, 119 completed the questionnaires, 88.6% were satisfied with the thoracoscopic video as a teaching tool, 86.4% were satisfied with the quality of the images, 69.2% perceived it to be beneficial in learning anatomy, 96.2% increased their interest in learning anatomy, and 88.5% wanted this new teaching tool to be implemented to the curriculum. Majority (80.7%) of the students increased their interest in surgery as a future career. Post-test scores were significantly higher in the thoracoscopy group (P = 0.0175). Conclusion: Incorporating live surgery using thoracoscopic video presentation in the gross anatomy teaching curriculum had high acceptance and satisfaction scores from first year medical students. The video increased students' interest in learning, in clinically applying anatomic fact, and in surgery as a future career.

Background Our objective is to ascertain if preoperative and perioperative treatments affect the short- and long-term symptom frequency or symptom scores for dysphagia, regurgitation, and heartburn in patients with laparoscopic Heller myotomy for achalasia. Methods From 1994 to 2008, 261 patients undergoing laparoscopic esophageal myotomy were enrolled prospectively. The diagnosis of classic achalasia was made on clinical history, barium swallow, endoscopy, and manometry. A validated symptom questionnaire and history was taken for each patient at the preoperative visit and at each postoperative visit. Results In all, 261 patients had laparoscopic Heller myotomy during the study period. Preoperatively, 137 patients (62.3%) tried medications, 101 (38.7%) were treated with pneumatic dilation, and 29 (11.1%) were treated initially with at least one injection of botulinum toxin into the lower esophageal sphincter. In all, 134 patients (51.3%) received a Dor anterior fundoplication. On multivariate regression controlling for age and sex, preoperative dilation ( p = 0.031), injection of botulinum toxin ( p = 0.044), and a fundoplication ( p = 0.005) were associated with significantly worse early postoperative dysphagia, with odds ratios of 2.11, 2.56, and 2.80, respectively; previous botulinum toxin injection was associated with worse late postoperative dysphagia ( p = 0.001), regurgitation ( p = 0.031), and heartburn ( p = 0.049), with odds ratios of 5.24, 2.87, and 2.52, respectively. There was a trend for no fundoplication to be associated with late postoperative heartburn ( p = 0.077) with an odds ratio of 1.80. Conclusions Many patients presenting for Heller myotomy have previously undergone a different form of treatment. Early postoperative dysphagia was affected by dilation, botulinum toxin injection, and fundoplication. Only botulinum toxin injection was associated with late symptoms.

Cervical esophagogastric anastomoses are commonly used for reconstruction after esophagectomy because of the lower mortality rate associated with an anastomotic leak compared to intrathoracic anastomoses. However, cervical esophagogastric anastomoses have been criticized for their higher leak rates, stricture formation and greater need for later dilatations when compared with intrathoracic anastomoses. Multiple studies have looked at varying techniques to improve the outcome of the cervical esophagogastric anastomosis. This study was performed to determine whether a partially stapled (posterior stapled wall and anterior hand-sewn wall) anastomosis reliably reduced leaks and the need for later dilatation. From January 2001 to March 2006, 168 patients who underwent cervical esophagogastric anastomosis following esophagectomy (transhiatal or three-hole) for cancer were identified. Beginning in September 2003, the partially stapled technique was introduced and used in 79 patients. Clinical outcomes were compared to patients in whom hand-sewn technique was used (n = 89). Outcomes related to anastomotic leak, other hospital complications, length of stay, postoperative dilatations and survival were compared using Student's t-tests and chi-square tests (P < 0.05), as well as multiple regression analyses. An anastomotic leak occurred in 10 (12.7%) patients who received a partially stapled anastomosis. A hand-sewn anastomosis was complicated by an anastomotic leak in 24 patients (27.0%). This difference was statistically significant (P = 0.021). This lowered incidence of leak was associated with an earlier initiation of oral feeds (median 7 vs. 9.5 days, P < 0.001) and a reduction in hospital stay (median 10 vs. 15 days, P < 0.001). Furthermore, dysphagia associated with stricture requiring postoperative dilatations was markedly diminished in the stapled anastomosis [23 (31.3%) vs. 49 (55.1%), P = 0.001]. The partially stapled cervical esophagogastric anastomosis significantly decreased the incidence of postoperative anastomotic leaks and the need for postoperative dilatation to treat strictures compared to the hand-sewn anastomosis.

Background The objective of this study was to combine systematic review and decision analytic techniques to determine the optimal treatment strategy for patients with locally advanced esophageal cancer. Methods We performed a systematic review of all randomized trials of patients with locally advanced esophageal cancer that included one of the following strategies compared with surgery alone: chemoradiotherapy followed by surgery, chemotherapy followed by surgery, or surgery with adjuvant chemoradiotherapy. Using the estimates of relative risk for mortality and overall quality of life we constructed a decision model. The outcome of interest was expected quality-adjusted life-years (QALY). Results The meta-analysis showed for the first year, the relative risk (95% confidence interval) of death for treatments compared with surgery were 0.87 (0.75 to 1.02) for chemoradiotherapy followed by surgery, 0.94 (0.82 to 1.08) for chemotherapy followed by surgery, and 1.33 (0.93 to 1.93) for surgery with adjuvant chemoradiotherapy. The QALYs gained for surgery alone, chemoradiotherapy followed by surgery, chemotherapy followed by surgery, and surgery with adjuvant chemoradiotherapy strategies were 2.07, 2.18, 2.14, and 1.99, respectively. If the reduction in utility for multimodality treatment was increased to 21%, the QALYs gained for surgery alone, chemoradiotherapy followed by surgery, chemotherapy followed by surgery, and surgery with adjuvant chemoradiotherapy were 2.07, 2.03, 1.99, and 1.85, respectively. Conclusions Chemoradiotherapy followed by surgery appears to be associated with the best survival and the largest expected gain in QALYs. However, the improvement in quality-adjusted life expectancy is modest at 40 days, and surgery alone becomes the preferred strategy if the reduction in utility associated with multimodality treatment is increased to 21%.

L ung cancer is the most common cause of cancer death for both men and women in the industrialized world. Small-cell lung cancer accounts for about 25% of lung cancers and is usually widespread by the time it is first seen. The remaining 75%of lung cancers are collectively termed non–small-cell lung cancers. When presentation is by symptoms or incidental discovery, about 50% to 60% of non–small-cell lung cancers are parenchymal nodules or masses, and 40% to 50% are bronchial or hilar. More than 50% of patients with non–small-cell lung cancer will have distant metastases at the time of diagnosis, and only 25%will have potentially resectable disease that can be cured. The overall survival rate at 5 years for lung cancer is approximately 15% and has not significantly improved over the last several decades. The prognosis for lung cancer is af

Objectives: We sought to test the safety and efficacy of fluoroscopically guided, video-assisted, thoracoscopic resection after computed tomography (CT)-guided localization using platinum microcoils. Summary Background Data: Video-assisted thoracoscopic (VATS) resection of small pulmonary nodules 5 mm deep to the visceral pleura fails to locate the nodule and requires conversion to open thoracotomy in two thirds of cases. Therefore, we developed a new technique for intraoperative localization of these nodules using CTguided placement of platinum microcoils. This study tests the safety and efficacy of this technique in a Phase I human study. Methods: Twelve patients with undiagnosed growing pulmonary nodules 20 mm were marked preoperatively using percutaneously placed CT-guided platinum microcoils. The coil was deployed adjacent to the nodule with the distal end of the coil placed deep to the nodule and the superficial end coiled on the pleural surface. The nodule and coil were excised using endostaplers guided by VATS and fluoroscopy. Histopathologic diagnosis was performed immediately after resection. Results: CT-guided microcoil localization was successful in all patients. A small hemothorax and a pneumothorax requiring a chest tube occurred in 2 patients. Mean distance from visceral pleura to the deep edge of the nodule was 30.9 15.4 mm. VATS resection of the nodules (size 11.8 3.2mm) was successful in all patients. Mean microcoil localization, fluoroscopy, and operative times were 42 14, 3.1 2.0, and 67 27 minutes. A diagnosis of primary nonsmall cell bronchogenic carcinoma was made in 6 patients who then received a completion lobectomy. Six patients (hamartoma: 2, reactive lymph node: 1, bronchoalveolar cell carcinoma: 2, metastatic sarcoma: 1) did not receive further resections. Conclusions: Preoperative localization of pulmonary nodules using percutaneous CT-guided platinum microcoil insertion combined with operative fluoroscopic visualization is a safe, effective technique that increases the success rate of VATS excision.

Quality-of-life measurement in controlled clinical trials assessing medical treatment has increased drammatically over the past decades. Although the experience with quality-of-life measurement in surgical clinical trials has been more recent, it has demonstrated the important role of these measures in determining the best treatment options as well as in clinical decisions. Two types of instruments are available to measure quality of life: generic instruments, and specific instruments. Both follow a rigorous scientific methodology that includes both a development and a validation phase. In the validation phase, instruments are assessed for their reproducibility, responsiveness, and validity. Ad hoc instruments, on the other hand, follow no such methodology and results can be open to interpretation. This review demonstrates that quality-of-life measurement in surgical clinical trials is both possible and clinically important. More study investigators will consider measuring quality of life using well-validated instruments when designing future surgical randomized controlled trials.

Background: The ideal treatment for achalasia permanently eliminates the dysfunctional lower esophageal sphincter, relieving dysphagia and regurgitation; prevents gastroesophageal reflux; and has an acceptable morbidity rate. Controversy exists concerning whether the thoracoscopic Heller Myotomy (THM) or laparoscopic Heller myotomy (LHM) technique is the best approach to a modified Heller myotomy for achalasia. Study Design: We performed a retrospective comparison of the patient characteristics, operative results, postoperative symptoms, and the learning curves for the procedures of 24 patients undergoing THM and 63 patients undergoing LHM between 1991 and 1998. Results: Preoperative patient variables in each group revealed similar distributions for age, gender, and prevalence of previous pneumatic dilation. Mean operating room (OR) times were 4.3 hours (range 2.9 to 5.6 hours) for THM and 3.0 hours (range 1.5 to 6.5 hours) for LHM (p = 0.01). Three esophageal perforations occurred in the THM group and two in the LHM group. Conversion to an open procedure took place in five THM operations (21%) and one LHM operation (2%) (p = 0.005). There were no postoperative esophageal leaks. Mean postoperative length of stay (LOS) for THM was 6.1 days (range 1 to 17 days) and for LHM was 4.0 days (range 1 to 12 days) (p = 0.03). Learning-curve analysis of the first 24 LHM patients compared with the most recent 24 revealed greater OR time in the first 24 mean 3.6 hours, (range 2.0 to 6.5 hours) versus mean 2.3 hours, (range 1.5 to 3.7 hours; p=0.01), and greater LOS mean 5.5 days, (range 3 to 12 days) versus mean 3.1 days, (range 1 to 8 days; p Conclusions: LHM was associated with decreased OR time, decreased rate of conversion to an open procedure, and shorter LOS compared with THM. LHM was superior to THM in relieving dysphagia and preventing heartburn. LHM may be the preferred surgical treatment of achalasia in some patients.

background The incidence of adenocarcinoma of the cardia is increasing. The surgical management remains controversial. The present study reviews our experience with surgically resected adenocarcinoma of the cardia. methods A retrospective review of 153 cases of surgically resected adenocarcinoma of the cardia was performed. Preoperative radiotherapy was used in 31 patients. The surgical approach, morbidity, mortality, impact of preoperative radiotherapy, and survival were determined. results The type of resection performed was a transhiatal esophagogastrectomy in 78%, a transthoracic esophagogastrectomy in 21%, and a transabdominal esophagogastrectomy in 1%. The in-hospital mortality rate was 4%. The frequency of complications was not associated with the use of preoperative radiotherapy or surgical approach. The 1-year (61%), 2-year (38%), 3-year (23%), and 5-year (16%) survival were not affected by the use of preoperative radiotherapy or surgical approach. Survival was significantly associated with stage and the presence of lymph node metastasis. conclusions Adenocarcinoma of the cardia is associated with a poor long-term prognosis. The long-term survival does not appear to be affected by the use of preoperative radiotherapy or by surgical approach.

Objective: To evaluate the clinical utility of a new portable ultrasound device (PUD) in the management of intermittent catheter programs in patients with neuropathic bladder. Design: Intervention study using randomized control trial. Setting: Tertiary care center providing inpatient and ambulatory rehabilitation services to persons with neurologic disabilities. Participants: Thirty-eight inpatients and outpatients with neuropathic bladders requiring intermittent catheterization. Main Outcome Measures: Mean frequency of intermittent catheterization, mean number of episodes of overdistension, and patient satisfaction as measured with a Patient Satisfaction Questionnaire. Results: The mean frequency of catheterization per day was reduced in the PUD group in comparison with controls (2.99 vs 4.12, p = .026). The number of episodes of overdistension was also reduced in the PUD group but did not reach statistical significance (12.45 vs 14.76, p = .61). Subjects generally expressed satisfaction with the PUD, with 16 of 18 patients at least somewhat satisfied with the device. Conclusion: The PUD is a useful tool for clinicians in patients undergoing intermittent catheterization programs that can reduce the number of required catheters. It is associated with a high degree of patient satisfaction.

Background and methods A Comparison of total vs. partial laparoscopic fundoplication was conducted in 89 patients from July 92 to June 96. Parameters examined were operating room (OR) times, conversion rates, and perioperative complications. Patient satisfaction, control of symptoms, and late complications were assessed by follow-up at a mean of 6 and 15.4 months. Results There were six conversions to open surgery resulting in 48 laparoscopic total (LTF) and 35 laparoscopic partial (25 anterior and 10 Toupet) fundoplications (LPF). The following results were obtained for each respectively: preop Demeester score 44 vs. 39; OR time 2.9 vs. 2.5 hours; length of stay 3.6 vs. 4.1 days; early morbidity 25% vs. 1%. There were no mortalities. At a mean follow-up of 6 months, new-onset dysphagia was present in 8 (17%) vs. 2 (8%), respectively (NS), and both total and partial fundoplications appeared successful in controlling symptoms (98% vs. 97%). At a mean follow-up of 15.4 months, heartburn was resolved or improved in 76% vs. 87% (NS); regurgitation was improved or resolved in 93% vs. 93%; and patient satisfaction with the procedure was present in 93% vs. 97% (NS). Persistent dysphagia was present in 7.3% vs. 10.3% (NS) of patients. Early satiety was present more often in the partial fundoplication group (56% vs. 83% P = .03). Conclusions Early follow-up suggests equal efficacy in controlling symptoms and in achieving patient satisfaction. A 6-month follow-up suggested a higher incidence of new dysphagia in the total fundoplication group; however, at 15-month follow-up there was no significant difference.

Background The frequency and causes of gastrointestinal complications following esophagectomy for malignancy are unknown. Patients and methods We reviewed 295 esophagectomies performed for malignancy between January 1980 and September 1994 in order to determine the frequency and causes of early and late gastrointestinal complications. Results Compared to transhiatal and left thoracoabdominal esophagectomies, esophagectomies carried out through a right posterolateral thoracotomy with cervical esophagogastric anastomosis had a higher incidence of delayed gastric emptying (11%), pneumonia (26%), and hospital death (9%). The same operation had a higher incidence of gastroesophageal reflux (20%) and dysphagia requiring esophageal dilatation (53%). We found no independent effect of gastric drainage procedures, feeding jejunostomy, preoperative radiotherapy, pathology, or age on these outcomes. Women had no operative mortality, but a higher incidence of gastroesophageal reflux and diarrhea following esophagectomy. Conclusions Surgical techniques aimed at improving gastric emptying following esophagectomy for cancer should improve operative morbidity and mortality.

Background: Public health care increasingly uses outreach models to engage individuals who are marginalized, many of whom misuse substances. Problematic substance use, together with marginalization from the health care system, among homeless adults makes it difficult to assess their capacity to consent to medical care. Tools have been developed to assess capacity to consent; however, these tools are lengthy and unsuitable for outreach settings. The primary objective of this study is to develop, validate, and pilot a brief but sensitive screening instrument which can be used to guide clinicians in assessing capacity to consent in outreach settings. The goal of this paper is to outline the protocol for the development of such a tool. Methods/Design: A brief assessment tool will be developed and compared to the MacArthur Competency Assessment Tool for Treatment (MacCAT-T). As list of 36 possible questions will be created by using qualitative data from clinician interviews, as well as concepts from the literature. This list will be rated by content experts according to the extent that it corresponds to the test objectives. The instrument will be validated with 300 homeless adult volunteers who self-report problematic substance use. Participants will be assessed for capacity using the MacCAT-T and the new instrument. A combination of Classical Test Theory and advanced psychometric methods will be used for the psychometric analysis. Corrected Item-Total correlation will be examined to identify items that discriminate poorly. Guided exploratory factor analysis will be conducted on the final selection of items to confirm the assumptions for a unidimensional polytomous Rasch model. If unidimensionality is confirmed, an unstandardized Cronbach Alpha will be calculated. If multi-dimensionality is detected, a multidimensional Rasch analysis will be conducted. Results from the new instrument will be compared to the total score from the MacCAT-T by using Pearson’s correlation test. The new instrument will then be piloted in real-time by street outreach clinicians to determine the acceptability and usefulness of the new instrument. Discussion: This research will build on the existing knowledge about assessing capacity to consent and will contribute new knowledge about assessing individuals whose judgment is impaired by substance use.

To prospectively assess the safety and effectiveness of computed tomography (CT)-guided placement of fiber-coated microcoils used to guide video-assisted thoracoscopic surgical (VATS) excision of small peripheral lung nodules, with successful excision as the primary outcome and successful CT-guided microcoil placement and procedural complications as secondary outcomes.The institutional review board approved the study protocol. Informed consent was obtained from all 69 enrolled patients (30 men, 39 women; mean age, 60.7 years +/- 10.1 [standard deviation]) with 75 nodules. At CT, one end of an 80-mm long, 0.018-inch-diameter fiber-coated microcoil was placed deep to the small peripheral lung nodule, and the other end was coiled in the pleural space. VATS excision of lung tissue, nodules, and the microcoil was performed with fluoroscopic guidance.Seventy-three (97%) 4-24-mm nodules were successfully removed at fluoroscopically guided VATS excision; two nodules could not be removed. CT-guided microcoil placement was successful in all cases; however, two (3%) of 75 coils were displaced at VATS excision. Pneumothorax requiring chest tube placement occurred in two (3%) patients, and asymptomatic hemothorax occurred in one (1%) patient. The microcoil did not impede intraoperative frozen-section histopathologic analysis, which facilitated accurate clinical management in all patients. For 19 (28%) patients, the preoperative treatment plan based on bronchoscopy, needle biopsy, and positron emission tomography findings changed after VATS excision.Microcoil localization of small peripheral lung nodules enabled fluoroscopically guided VATS resection of 97% of the nodules, with a low rate of intervention (3%) for procedural complications.

Our primary objective was to evaluate demographic and causal factors of inhospital mortality for significant firearm-related injuries (i.e., those with an Injury Severity Score [ISS]12) in Canadian trauma centres.We analyzed data submitted to the Canadian Institute for Health Information (CIHI) in the National Trauma Registry for all firearm-injured patients for fiscal years 1999-2003. Univariate and bivariate adjusting for ISS and multivariate logistic regression were performed.Men accounted for 94% of the 784 injured. In all patients, the percentages of self-inflicted, intentional, unintentional and unknown injuries were 27.8%, 60.3%, 6.1% and 5.7%, respectively. The inhospital fatality rate was 39.8%, with 83% of fatalities occurring on the first day. Two-thirds of patients were discharged home. Univariate and adjusted analysis found that ISS, first systolic blood pressure (BP), first systolic BP under 100, first Glasgow Coma Scale (GCS) score, age over 45 years, self-inflicted injury, intentional injury and injury at home significantly worsened the odds ratio of death in hospital and that police shooting was relatively beneficial. BP under 100, age over 45 years and a low GCS score had an adjusted odds ratio of death of 4.12, 1.99 and 0.64 per point increase, respectively. The multivariate model showed that ISS, BP under 100, first GCS score, sex and self-inflicted injury were significant in predicting inhospital death.A predominance of young men are injured intentionally with handguns in Canada, whereas older patients suffer self-inflicted injuries with long guns. The significant number of firearm deaths, largely in the first day, highlights the importance of preventative strategies and the need for rapid transport of patients to trauma centres for urgent care.

BACKGROUND: Empyema is a suppurative infection of the pleural space. Without prompt treatment, it can result in significant hospital stays, more invasive treatments as it progresses, and substantial morbidity and mortality.OBJECTIVES: The primary objective of the present study was to evaluate whether there has been an increasing incidence of empyema in Canada. A secondary objective was to investigate whether this increase disproportionately affects any age group.METHODS: The Discharge Abstract Database of the Canadian Institute for Health Information was used to evaluate national empyema data.RESULTS: There were 11,294 patients identified with empyema over the nine-year period of the present study, of whom 31% were women. The mean (± SD) length of stay was stable throughout the study at 21.82±33.88 days, and 63.4% were discharged home. The incidence rate ratio (IRR) was defined as the ratio of the incidence rate of medical empyema in 2003 divided by the incidence rate in 1995. Medical empyema increased significantly (IRR 1.30, 95% CI 1.20 to 1.41; PCONCLUSIONS: The present study demonstrates the increasing rate of empyema in Canada and shows a change in pattern of disease. The disproportionate rate change in the pediatric population suggests a high-risk group that needs to be addressed. In the adult population, while cause is unknown, it is necessary to continually educate front-line physicians to confront both the increased burden of this disease, caused by an aging population, and the underlying increasing rate of empyema in Canada.

Achalasia is a primary motor disorder of the esophagus characterized by an abnormal hypertensive, nonrelaxing lower esophageal sphincter (LES) and nonfunctioning, aperistaltic esophageal body resulting in significant regurgitation and dysphagia. The primary goal of treatment is palliation of symptoms. At present, all treatment techniques are directed at relieving the functional obstruction at the level of the LES by disruption or paralysis of the esophageal muscle constituting the LES. Destruction of the LES function also places the patient at risk for pathologic gastroesophageal reflux disease. Therefore, the treatment of patients with achalasia must strike a balance between the relief of dysphagia and potential creation of pathologic gastroesophageal reflux. The advent of laparoscopic esophageal myotomy for the treatment of achalasia over the past decade has resulted in most patients with the disease being referred to surgeons for definitive treatment. At the time of consultation the patient may present with a myriad of symptoms, investigative results, and previous treatments. Based on our experience of over 300 patients treated with surgery at our institution between 1990 and 2007, this review will address the practical problems encountered in the surgical management of achalasia.

SUMMARY. The objective was to develop, pretest and validate a disease-specific quality of life questionnaire for potentially curable patients with esophageal carcinoma, for use with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in order to assess the quality of life associated with the various treatment modalities available for this disease. Questionnaire development phase Patients were enrolled in three centres. Literature reviews, patients, family members, and health care professionals generated 195 items: symptoms (55); emotions (53); physical functioning (17); activities of daily living (ADL) (48); and leisure/social (22). Thirty-eight patients identified items of importance and assigned importance ratings on a 5-point Likert scale. Impact scores were calculated as frequency times mean item importance. Item impact scores

Anterior fundoplication (AF) following laparoscopic Heller myotomy (LHM) for achalasia may prevent esophageal leaks and gastroesophageal reflux but cause dysphagia. Our study attempts to determine the effect of AF on esophageal leaks, nuclear medicine esophageal clearance (EC), symptom frequency (SF), and Van Trappen symptom scores (SS) for dysphagia, regurgitation, and heartburn.Between 1995 and 2004, pre- and postoperative (2-12 months) EC, SF, and SS scores were compared in 95 patients undergoing LHM for achalasia with AF (n = 71) and without (n = 24) AF.There were no leaks or deaths. Laparoscopic Heller myotomy decreased the frequency of postoperative dysphagia, regurgitation, and heartburn with AF (96% preoperation versus 6% postoperation, 94% versus 3%, 58% versus 6%) (p = 0.001) and without AF (100% versus 0%, 83% versus 0%, 50% versus 4%) (p = 0.001). Laparoscopic Heller myotomy improved all SS in both groups. There was no difference between postoperative dysphagia (1.38 +/- 0.64 versus 1.17 +/- 38) p = 0.06, regurgitation (1.17 +/- 51 versus 1.04 +/- 0.20) p = 0.08, and heartburn (1.29 +/- 62 versus 1.53 +/- 0.80) p = 0.185 scores between the AF and no-AF group, respectively. There is a trend toward improvement in dysphagia and regurgitation in the no-AF group. Laparoscopic Heller myotomy improved EC in the supine and upright positions in both groups of patients (p = 0.001). There was an improved mean change in EC (10 min upright) in the no-AF group versus the AF group (50.7% +/- 30.8 versus 29.7% +/- 30.2) p = 0.004.Laparoscopic Heller myotomy improves esophageal transit and the frequency and severity of dysphagia, heartburn, and regurgitation in a safe manner. Patients without AF show a statistically better upright EC with a trend toward improved dysphagia and regurgitation.

Platinum microcoils were placed in porcine lungs to determine the feasibility for use as a lung nodule marker. Using computed tomography (CT) guidance, the microcoils were successfully deployed in 17 out of 19 attempts. Coil deployment depth ranged from 7 mm to 34 mm below the pleural surface. Moderate pneumothorax was detected after 3 of 19 microcoil insertions. No hemothorax or significant pulmonary hemorrhage was noted. Fluoroscopic guided thoracoscopic resection was successful in 10 of 12 attempts. Platinum microcoils can be safely and easily deployed into the lung parenchyma with minimal complication risk, and can be used to guide subsequent thoracoscopic wedge resection.

Laparoscopic Heller esophageal myotomy improves esophageal clearance and symptoms of achalasia in the early and late postoperative periods.We followed up 98 consecutive patients attending a referral center between February 1, 1994, and July 1, 2000, who underwent laparoscopic myotomy. Operative time, complications, and length of stay were recorded. Postoperative outcomes were assessed using Van Trappen symptom scores (1 indicates no symptoms; 2, symptoms occurring less than once a week; 3, symptoms occurring more than once weekly; and 4, persistent symptoms) and scintigraphic esophageal transit studies.Of 98 patients, 91 underwent anterior fundoplication. There were no open conversions and 1 mucosal perforation, which was closed laparoscopically without complications. Mean operative times and postoperative days were 3.2 hours and 4.3 days, respectively, in the first 32 patients and 1.7 hours and 2.3 days, respectively, in the last 32 patients (P.001). Postoperative complications included pneumothorax (4% of patients), atelectasis (5%), and delayed gastric emptying (1%). Seventy-five percent of patients gained weight after surgery. At longest follow-up, 91% of patients were satisfied with the outcome of the procedure. Mean Van Trappen scores for dysphagia improved from 4.0 in the preoperative period to 1.2 at early and late follow-up (P.001). Fluid retention at 10 minutes in the upright position was 47% in the preoperative period and improved at early and late follow-up to 21% and 20%, respectively (P.001).Laparoscopic Heller myotomy can safely reverse the symptoms of achalasia and improve esophageal transit. These benefits, realized during the early postoperative period, were maintained at longest follow-up.

Background . The purpose of this study was to determine the initial results of laparoscopic esophageal myotomy and anterior fundoplication in the treatment of 26 patients with achalasia. Methods . Operative time, complications, and length of hospitalization were recorded for each patient. Postoperative outcomes were assessed by a standardized patient questionnaire, 24-hour esophageal pH studies, and esophageal transit studies. Results . Twenty-six consecutive patients with class IV dysphagia underwent a laparoscopic esophageal myotomy and anterior partial fundoplication, with a single incidence of intraoperative esophageal perforation. The mean operative time was 3.5 hours. The median length of hospitalization was 5 days. Of the 21 patients for whom follow-up was available (median follow-up, 4 months), 19 (90%) were satisfied and 2 (10%) were somewhat satisfied with their surgery. After operation, 14 of the 21 patients (67%) reported no dysphagia (class I), whereas 6 (28%) had class II dysphagia (less than once per week) and only 1 (5%) had class III dysphagia (greater than once per week). Liquid-phase esophageal transit studies (n = 14) revealed a significant improvement in esophageal clearance in the supine position from 18% before operation to 44% after operation ( p = 0.006). Distal esophageal acid exposure was normal in 6 of 7 patients. Conclusions . These early results suggest that laparoscopic esophageal myotomy and anterior partial fundoplication provides efficacious treatment of achalasia.