Economic impact of an enhanced recovery pathway for oesophagectomy.

BACKGROUND: Data are lacking to support the cost-effectiveness of enhanced recovery pathways (ERP) for oesophagectomy. The aim of this study was to investigate the impact of an ERP on medical costs for oesophagectomy. METHODS: This study investigated all patients undergoing elective oesophagectomy between June 2009 and December 2011 at a single high-volume university hospital. From June 2010, all patients were enrolled in an ERP. Clinical outcomes were recorded for up to 30 days. Deviation-based cost modelling was used to compare costs between the traditional care and ERP groups. RESULTS: A total of 106 patients were included (47 traditional care, 59 ERP). There were no differences in patient, pathological and operative characteristics between the groups. Median length of hospital stay (LOS) was lower in the ERP group (8 (interquartile range 7-18) days versus 10 (9-18) days with traditional care; P = 0·019). There was no difference in 30-day complication rates (59 per cent with ERP versus 62 per cent with traditional care; P = 0·803), and the 30-day or in-hospital mortality rate was low (3·8 per cent, 4 of 106). Costs in the on-course and minor-deviation groups were significantly lower after implementation of the ERP. The pathway-dependent cost saving per patient was €1055 and the overall cost saving per patient was €2013. One-way sensitivity analysis demonstrated that the ERP was cost-neutral or more costly only at extreme values of ward, operating and intensive care costs. CONCLUSION: A multidisciplinary ERP for oesophagectomy was associated with cost savings, with no increase in morbidity or mortality.

Operative management of "hockey groin syndrome": 12 years of experience in National Hockey League players.

BACKGROUND: At the elite level of hockey, groin injuries can threaten a player's career. The aim of this review is to describe the clinical presentation and evaluate our operative approach to "hockey groin syndrome" in National Hockey League (NHL) players. METHODS: Between November 1989 and June 2000, 22 NHL players with debilitating groin pain underwent operative exploration. A repair, including ablation of the ilioinguinal nerve and reinforcement of the external oblique aponeurosis with a Goretex (W.L. Gore & Associates, Inc, Flagstaff, Ariz) mesh, was performed. Medical records were reviewed, and the players or their trainers were contacted by telephone after a mean follow-up period of 31.2 months to assess function, symptoms, and overall satisfaction. RESULTS: All patients had tearing of the external oblique aponeurosis, with branches of the ilioinguinal nerve emerging from the torn areas. At follow-up, 18 players (82%) had no pain, whereas 4 (18%) reported mild, intermittent pain. All 22 patients returned to playing hockey, with 19 (85%) able to continue their careers in the NHL. CONCLUSIONS: The "hockey groin syndrome," marked by tearing of the external oblique aponeurosis and entrapment of the ilioinguinal nerve, is a cause of groin pain in professional hockey players. Ilioinguinal nerve ablation and reinforcement of the external oblique aponeurosis successfully treats this incapacitating entity.

Pulmonary metastases from colorectal cancer: 25 years of experience.

OBJECTIVE: To examine the experience of pulmonary resections for colorectal metastases at the McGill University Health Centre. DESIGN: A chart review. PATIENTS: Forty-nine patients treated surgically between 1975 and 1998 for pulmonary metastases from colorectal cancer. INTERVENTION: Thoracotomy with pulmonary resection. OUTCOME MEASURES: Survival of patients with various preoperative and post operative clinical variables. RESULTS: The perioperative death rate was 4%. Overall 5- and 10-year survival rates were 55% and 40% respectively. The mean interval between the initial colonic resection and resection of pulmonary metastases (discase-free interval) was 36 months. The 7 patients who also under went resection of extrapulmonary metastases had a 5-year survival rate of 52%. Significant preoperative variables that carried a poor prognosis included the following: more than one pulmonary lesion, a disease-free interval of less than 2 years, and moderately or poorly differentiated colorectal cancer. The 16 patients who received chemotherapy after their thoracotomy had a 5-year survival rate of 51% compared with 54% for the 33 patients who did not receive chemotherapy. Recurrent resections of pulmonary lesions did not reduce survival. CONCLUSIONS: Pulmonary resection for metastatic colorectal cancer is both effective and safe. Resectable extrapulmonary metastases and pulmonary recurrence should not preclude lung resection. Postoperative chemotherapy has no survival benefit. Preoperative variables should guide the clinician when considering surgical intervention.

Lower abdominal pain syndrome in national hockey league players: a report of 11 cases.

PURPOSE: Groin injuries are a major diagnostic and therapeutic challenge in sports medicine. The aim of this review is to describe the clinical and surgical findings associated with an atypical lower abdominal pain syndrome occurring in elite ice hockey players. CASE SUMMARIES: Eleven professional ice hockey players from various National Hockey League teams were referred to the Montreal General Hospital between 1989 and 1996, suffering from atypical refractory pain and paraesthesia in the lower abdomen. Despite the use of conventional investigative procedures such as physical examination, ultrasound, bone scan, computed tomography scan, and magnetic resonance imaging scan, preoperative findings were consistently negative. Operative findings revealed varying degrees of tearing of the external oblique aponeurosis and external oblique muscle associated with ilioinguinal nerve entrapment. Repair of the external oblique tear, ablation of the ilioinguinal nerve, followed by a 12-week planned course of physiotherapy allowed all to return to professional ice hockey careers. DISCUSSION: While soft tissue injuries are the most common cause of groin pain in the athlete, tears of the external oblique aponeurosis and superficial inguinal ring have rarely been cited as a consistent cause of lower abdominal pain in athletes. Inguinal nerve entrapment is also rare in patients without a history of previous lower abdominal surgery. RELEVANCE: These 11 cases emphasize the importance of including another diagnostic possibility in the differential diagnosis of chronic overuse injuries of the lower abdomen.

Transesophageal echocardiography for ascending aortic dissection: is it enough for surgical intervention?

BACKGROUND: Acute ascending aortic dissection is a surgical emergency that requires expeditious diagnosis and prompt surgical intervention. In many centers, transesophageal echocardiography (TEE) is the test of choice on which surgical decisions are based. Echocardiographic false-positive diagnoses are rare but can occur with potentially severe consequences. CASE REPORT: Two clinical cases where ascending aortic dissections were falsely diagnosed by TEE are presented. DISCUSSION: Recent literature comparing the diagnostic accuracy of TEE and other imaging techniques are reviewed. Anatomical limitations of TEE and potential causes of false-positive results are discussed. Multiplane probe reduces, but does not eliminate, the occurrence of false-positive findings. To improve diagnostic specificity without undue delays in the course of clinical decision making, we recommend dividing positive TEE findings into "definite" and "probable" categories. Such subclassification is helpful in identifying cases where additional confirmatory tests are desirable in situations of uncertain diagnosis.

Bronchial carcinoid--twenty years' experience defines a selective surgical approach.

BACKGROUND: The purpose of this study was to look at the clinical behavior of bronchial carcinoids and clarify a surgical approach. METHODS: Eighty-four patients resected for bronchial carcinoids were retrospectively reviewed for clinicopathologic variables, surgical management, and outcome. Tumors were considered "typical" or "atypical" based on histologic features. "Conservative" surgery signified lung parenchyma-sparing procedures. Survival analysis was performed using standard statistical methods. RESULTS: Most patients presented with an abnormal routine chest x-ray. One patient had the carcinoid syndrome. Computed tomography scan reliably predicted lymph node status and bronchoscopic biopsy diagnosed carcinoids with 70% success. Fifteen "conservative" procedures were performed. Fifteen percent of patients had atypical carcinoids, 12% presented with lymph node metastases, and 6 patients had tumorlets associated with the primary tumor. Overall survival rates were 93% and 82% at 5 and 10 years, respectively. Significantly decreased disease-free survival was found with atypical histology (p < 0.0001) and the presence of tumorlets (p = 0.02); lymph node involvement strongly tended toward poorer outcome. CONCLUSIONS: Bronchial carcinoids have a definite malignant potential predicted by atypical histology, presence of tumorlets, and lymph node involvement. These features can be identified with routine bronchoscopic biopsy, computed tomography scanning, and intraoperative assessment including frozen section. In the select group of patients without negative features, strong consideration should be given to performing a conservative resection.

Profound hypotension in blunt trauma associated with superior gluteal artery rupture without pelvic fracture.

Superior gluteal artery injury is a rare but well-known complication of abdominal trauma, usually in association with pelvic fractures. Embolization has become the most effective treatment for pelvic hemorrhage with regard to superior gluteal artery injury, due to difficult surgical access. We report an unusual case of a superior gluteal artery rupture without pelvic fracture. The patient presented with profound hypotension after blunt trauma. Angiography revealed an injured superior gluteal artery, which was successfully embolized.

Duodenal perforation by a Greenfield filter: endoscopic diagnosis.

Despite its proven safety and efficacy, complications from the Greenfield vena cava filter have been described. We report the unusual case of a duodenal perforation by a filter in a 29-yr-old male. The diagnosis was made incidentally at endoscopy.

Perioperative mortality after pneumonectomy: analysis of risk factors and review of the literature.

OBJECTIVE: To determine risk factors for perioperative death associated with pneumonectomy. DESIGN: A retrospective case-control study in which a perioperative death group was compared with a survivor group, and a review of the English literature on the subject. SETTING: The Montreal General Hospital, a tertiary-care teaching institution. PATIENTS AND INTERVENTION: Ninety-two consecutive patients who underwent pneumonectomy between April 1989 and 1994. MAIN OUTCOME MEASURES: The effects of age, sex, smoking history, tumour size, type and stage, pulmonary function, cardiovascular risks, comorbidity, preoperative blood values and volume of fluids administered perioperatively. Values from the literature were reported for comparison. RESULTS: The perioperative death rate was 10.9%. Selection bias and in-hospital values reported in the literature have underestimated the death rate, with actual rates ranging from 7% to 11%. Age (odds ratio 2.48, p = 0.04), the presence of 1 or more comorbid diseases (odds ratio 7.92, p = 0.05) and amount of fluids given in the first 12 hours postoperatively (odds ratio 2.21, p = 0.06) were found to be significant risk factors for death. Multivariate logistic regression demonstrated that the volume of fluids given remains an independent risk factor whereas age and comorbid disease are dependent variables. CONCLUSIONS: The results were consistent with previously reported death rates and risk factors. Patient age and concomitant disease are not modifiable risk factors, but perioperative fluid administration and other means to prevent postpneumonectomy pulmonary edema may reduce the perioperative death rate.

Laryngotracheal trauma.

Isolated trauma to the airway is infrequent yet potentially life-threatening. The larynx and cervical trachea are vulnerable to external forces, whether penetrating or blunt, as well as internal injuries from endotracheal or nasogastric intubation and to thermal burns from the inhalation of fumes or the ingestion of caustic substances.

Educating tomorrow's cardiac and thoracic surgeons: a Canadian initiative.

Societal, technologic, organizational and educational developments during the past 10 years have brought about increasing promises for change in the graduate medical education of cardiac and thoracic surgeons. These changes effectively lengthened training to 8'years and created a double standard for the education of a thoracic surgeon. A task force mandated by the Royal College of Physicians and Surgeons of Canada nucleus committees in both cardiac and thoracic surgery and with the support of the Canadian Society of Cardiovascular and Thoracic Surgeons studied the problem and made the following recommendation: cardiac surgery and thoracic surgery should each become a primary specialty with its own nucleus committee. Each specialty would require 6'years' training, with the possibility of obtaining certification in both specialties after an additional 18'months training. Each specialty could also be entered after completion of full training in general surgery. The task force also urged the development of a curriculum to guide educational objectives in each specialty. These changes will produce a flexible, shorter, more focused program for cardiac and thoracic surgeons for both university and community settings.

Video-assisted thoracoscopic wedge resection of T1 lung cancer in high-risk patients.

OBJECTIVE: This study assessed the reliability and safety of VATR for treatment of peripheral T1 lung cancer in high-risk patients. SUMMARY BACKGROUND DATA: Surgical resection is the best therapy for stage I lung cancer. Patients with poor cardiopulmonary status or those who are elderly (> 75 years of age) are considered to be at high risk from thoracotomy and are frequently referred for radiation therapy or expectant palliative management. Data from previous studies suggest that survival with wedge resection is similar to that with lobectomy. The authors propose VATR, which is minimally invasive, as a therapeutic option in patients considered to be at high risk for resection by thoracotomy. METHODS: Between November 1990 and November 1992, more than 400 thoracoscopic lung resections were performed. Thirty patients with poor pulmonary function (forced expiratory volume FEV1] < 1 L or < 35% predicted; arterial oxygen tension [PaO2] < 60 mmHg on room air; diffusion capacity [DCO] < 40%) underwent 31 VATRs (1 patient had a staged procedure for bilateral synchronous lung cancers). All patients had T1 peripheral lesions with no bronchoscopically visible lesions. Computed tomography of the chest revealed no evidence of mediastinal disease in all patients. RESULTS: Patients had a mean FEV1 value of 0.9 L (38% predicted) and a mean age of 71 years. Tumors were located in left upper lobe (LUL) in 13 patients, in right lower lobe (RLL) in 7 patients, in right upper lobe (RUL) in 6 patients, in left lower lobe (LLL) in 4 patients, and in right middle lobe (RML) in 1 patient. Computed tomography-guided wire localization, methylene blue surface injection, and intraoperative ultrasonography were used to assist in defining difficult lesions. All lesions were successfully resected without converting to thoracotomy. One patient died on the 34th postoperative day of myocardial infarction (operative mortality rate of 3%). Five patients had prolonged air leaks (< 5 days), with a median chest tube time of 3 days. Two patients experienced pneumonia. CONCLUSION: The authors concluded that VATR is a safe and reliable procedure for treatment of peripheral T1 lung cancer in high-risk patients. Long-term follow-up will be required to determine the efficacy of this procedure regarding survival and locoregional recurrence.