Biniam Kidane

Natural history of minimal aortic injury following blunt thoracic aortic trauma

BACKGROUND Endovascular repair of blunt traumatic thoracic aortic injuries (BTAI) is common at most trauma centres, with excellent results. However, little is known regarding which injuries do not require intervention. We reviewed the natural history of untreated patients with minimal aortic injury (MAI) at our centre. METHODS We conducted a retrospective database review to identify all patients with a BTAI between October 2008 and March 2010. The cohort comprised patients initially untreated because of the lesser degree of injury of an MAI. We reviewed initial and follow-up computed tomography (CT) scans and clinical information. RESULTS We identified 69 patients with a BTAI during the study period; 10 were initially untreated and were included in this study. Degree of injury included intimal flaps (n = 7, 70%), pseudoaneurysms with minimal hematoma (n = 2, 20%) and circumferential intimal tear (n = 1, 10%). Six (60%) patients were male, and the median age was 40 years. Duration of clinical follow-up ranged from 1 month to 6 years (median 2 mo) after discharge, whereas CT radiologic follow-up ranged from 1 week to 6 years (median 6 wk). Seven (70%) patients had complete resolution or stabilization of their MAI, 1 (10%) with circumferential intimal tear showed extension of the injury at 8 weeks postinjury and underwent successful repair, and 2 (20%) were lost to follow-up. CONCLUSION There appears to be a subset of patients with BTAI who require no surgical intervention. This includes those with limited intimal flaps, which often resolve. Radiologic surveillance is mandatory to ensure MAI resolution and identify any progression that might prompt repair.

MDT lung cancer care: Input from the Surgical Oncologist

Although there have been many advancements in the multidisciplinary management of non‐small cell lung cancer (NSCLC), surgery remains the primary modality of choice for resectable lung cancer when the patient is able to tolerate lung resection physiologically. There have been recent advances in surgical diagnosis and treatment of lung cancer. Increasing use of low‐dose computed tomography (CT) screening for lung cancer has resulted in increased detection of small peripheral nodules or semi‐solid ground glass opacities. Here, we review different modalities of localization techniques that have been used to aid surgical excisional biopsy when needle biopsy has failed to provide tissue diagnosis. We also report on the current debates regarding the use of sublobar resections for Stage I NSCLC as well as the surgical management of locally advanced NSCLC. Finally, we discuss the complex surgical management of T4 NSCLC lung cancers.

Pretreatment quality-of-life score is a better discriminator of oesophageal cancer survival than performance status

OBJECTIVES Performance status [Eastern Cooperative Oncology Group (ECOG)] is a physician-assigned score indicating a patients fitness for treatment. Functional assessment of cancer therapy-esophagus (FACT-E) is a patient-reported, health-related quality-of-life (HRQOL) instrument containing an oesophageal cancer subscale (ECS). Our objective was to assess the discriminative ability of pretreatment FACT-E and ECS when compared with performance status in predicting survival in patients with Stage II–III oesophageal cancer. METHODS Patient data from four prospective studies were pooled together. These four studies included oesophageal patients who received chemoradiation either as neoadjuvant therapy or as definitive therapy. Three separate Cox regressions were performed considering FACT-E, ECS and ECOG as the main predictors, respectively. Receiver-operating characteristics analyses were performed. RESULTS Of the 120 curative intent patients, 39.8% (n = 51), 58.6% (n = 75) and 1.6% (n = 2) had ECOG 0, 1 and 2, respectively. On Cox regression analysis, pretreatment FACT-E (P = 0.04) and ECS (P = 0.004) but not ECOG (P = 0.27) were independently associated with overall survival. ECOG could not discriminate between survivors and non-survivors (P = 0.28) with an area under the curve (AUC) of 0.56 [95% confidence interval (CI): 0.45–0.66], whereas FACT-E (P = 0.02) and ECS (P < 0.001) were discriminative with AUC = 0.63 (95% CI: 0.52–0.73) and AUC = 0.69 (95% CI: 0.60–0.79), respectively. CONCLUSIONS In patients with Stage II–III oesophageal cancer being considered for curative therapy, pretreatment FACT-E and ECS have better discrimination for survival than does ECOG. The majority of patients were ECOG 0/1. Thus, these patient-derived scores were able to discriminate survivors from non-survivors even within this constrained range of clinician-assigned performance status. This highlights the potential utility of FACT-E and ECS as prognostic tools.

Survival Prediction Tools for Esophageal and Gastroesophageal Junction Cancer: A Systematic Review

Background Clinical, pathological, and molecular information combined with cancer stage in prognostication algorithms can offer more personalized estimates of survival, which might guide treatment choices. Our aim was to evaluate the quality of prognostication tools in esophageal cancer. Methods We systematically searched MedLine and Embase from 2005 to 2017 for studies reporting development or validation of models predicting long‐term survival in esophageal cancer. We evaluated tools using the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies guidelines and the American Joint Committee on Cancer acceptance criteria for risk models. Results We identified 16 prognostication tools for patients treated with curative intent and 1 for patients with metastatic disease. These tools frequently excluded adenocarcinoma, contained outdated data, and were developed with a limited sample size. Nine tools were developed in China for squamous cell cancer, and 11 used data on patients diagnosed before 2010. Most tools excluded key prognostic factors such as age and sex. Tumor stage and grade were the most commonly, but not universally, included factors. Twelve tools were designed to predict overall survival; 5 predicted cancer‐specific survival. Bootstrap internal validation was performed for most tools; c‐statistics ranged from 0.63 to 0.77 and graphically evaluated calibration was “good.” Five tools were externally validated; c‐statistics ranged from 0.70 to 0.77. Conclusions Existing tools cannot be confidently used for esophageal cancer prognostication in current clinical practice. Better‐quality tools might help to more individually and accurately estimate disease course, select further treatments, and risk‐stratify for future clinical trials.

Polyethylene glycol intestinal lavage in addition to usual antibiotic treatment for severe Clostridium difficile colitis: a randomised controlled pilot study

Introduction Clostridium difficile infections (CDI) are common, costly and potentially life threatening. Most CDI will respond to antibiotic therapy, but 3%–10% of all patients with CDI will progress to a severe, life-threatening course. Complete removal of the large bowel is indicated for severe CDI. However, the 30-day mortality following surgical intervention for severe CDI ranges from 20% to 70%. A less invasive approach using surgical faecal diversion and direct colonic lavage with polyethylene glycol (PEG) and vancomycin has demonstrated a relative mortality reduction of approximately 50%. As an alternative to these operative approaches, we propose to treat patients with bedside intestinal lavage with PEG and vancomycin instillation via nasojejunal tube, in addition to usual antibiotic management. Preliminary data collected by our research group are encouraging. Methods and analysis We will conduct a 1-year, single-centre, pilot randomised controlled trial to study this new treatment strategy for patients with severe CDI and additional risk factors for fulminant or complicated infection. After informed consent, patients with severe-complicated CDI without immediate indication for surgery will be randomised to either usual antibiotic treatment or usual antibiotic treatment with the addition of 8 L of PEG lavage via nasojejunal tube. This pilot trial will evaluate our eligibility and enrolment rate, protocol compliance and adverse event rates and provide further data to inform a more robust sample size calculation and protocol modifications for a definitive multicentre trial design. Based on historical data, we anticipate enrolling approximately 24 patients during the 1-year pilot study period. As a pilot study, data will be reported in aggregate. Between-group differences will be assessed in a blinded fashion for evidence of harm, and to further refine our sample size calculation. Ethics and dissemination This study protocol has been reviewed and approved by our local institutional review board. Results of the pilot trial and subsequent main trial will be submitted for publication in a peer-reviewed journal. Trial registration number NCT02466698; Pre-results.

Use of Serotonergic Drugs in Canada for Gastrointestinal Motility Disorders: Results of a Retrospective Cohort Study

Background. Surgery for GI dysmotility is limited to those with severe refractory disease. Though effective, use of serotonergic promotility drugs has been restricted in Canada due to adverse events. We aimed to investigate utilization of promotility serotonergic drugs in patients under consideration for surgical management. Methods. A retrospective cohort study was conducted using prospectively collected data. The study population included consecutive patients referred to a motility clinic for consideration of bowel resection at a Canadian tertiary hospital (1996–2011). Univariable tests and multivariable logistic regression analyses were used to assess predictors of serotonergic drug use. Results. Of 128 patients, the majority (n = 98, 76.6%) had constipation-dominant symptoms. Only 25% (n = 32) had tried serotonergic promotility drugs. There was no association between use of these drugs and severity of constipation nor was there an association between serotonergic drug use and presence of diffuse dysmotility (all p > 0.05). The majority of patients (n = 97, 75.8%) underwent some type of surgical resection, which was associated with considerable morbidity (n = 13, 13.4%). Conclusions. Surgical management of GI dysmotility results in serious morbidity. Serotonergic promotility drugs may allow patients to avoid surgery but disease severity does not predict use of these drugs.

Photodynamic Therapy in Non-Gastrointestinal Thoracic Malignancies

Photodynamic therapy has a role in the management of early and late thoracic malignancies. It can be used to facilitate minimally-invasive treatment of early endobronchial tumours and also to palliate obstructive and bleeding effects of advanced endobronchial tumours. Photodynamic therapy has been used as a means of downsizing tumours to allow for resection, as well as reducing the extent of resection necessary. It has also been used successfully for minimally-invasive management of local recurrences, which is especially valuable for patients who are not eligible for radiation therapy. Photodynamic therapy has also shown promising results in mesothelioma and pleural-based metastatic disease. As new generation photosensitizers are being developed and tested and methodological issues continue to be addressed, the role of photodynamic therapy in thoracic malignancies continues to evolve.

Emergency department use is high after esophagectomy and feeding tube problems are the biggest culprit

Objectives: Esophagectomy is a complex operation with potential for prolonged recovery. We aimed to identify the incidence of and risk factors for any and frequent emergency department visits within 1 year of esophagectomy. Methods: A retrospective cohort study was performed looking at consecutive esophagectomies at a tertiary Canadian center (1999–2014). Multivariable analyses identified factors associated with any emergency department visits and frequent emergency department use (≥3 visits) within 1 year postesophagectomy. Results: There were 520 esophagectomies with in‐hospital mortality of 6% (n = 31). Of those discharged, 29.7% (n = 145) had ≥ 1 emergency department visit. Most common causes were feeding tube problems (39.3%; n = 57) and dysphagia/stricture (13.1%; n = 19). Higher income (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04–1.42 per

Stereotactic body radiation therapy versus video-assisted thoracoscopic surgery in stage I lung cancer: Honesty in the face of uncertainty

10,000) and use of hybrid/minimally invasive esophagectomy (aOR, 3.24; 95% CI, 1.71–6.11) were independently associated with having emergency department visits. Patients with hybrid/minimally invasive esophagectomy were discharged earlier than others (P < .0001). Living outside of our metropolitan area (aOR, 0.36; 95% CI, 0.27–0.49) and having surgery in the later years of the study period (aOR, 0.91; 95% CI, 0.86–0.97; P = .006) were both independently associated with lower odds of emergency department visits. Forty‐three patients (8.8%) were frequent emergency department users, with the most common causes of repeat emergency visits being feeding tube problems. Living outside of our metropolitan area was associated with lower odds of frequent emergency visits (aOR, 0.25; 95% CI, 0.14–0.45). Conclusions: There is high emergency department use within 1 year postesophagectomy. Patients living farther away from our hospital had a lower rate of emergency department use. It is possible that they are utilizing emergency departments nearer to home; this needs further study. Feeding tube problems are the biggest culprits and are potentially modifiable.

Is tissue still the issue? Lobectomy for suspicious lung nodules without confirmation of malignancy

From the Section of Thoracic Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. Disclosures: Author has nothing to disclose with regard to commercial support. Received for publication Aug 4, 2017; accepted for publication Aug 19, 2017. Address for reprints: Biniam Kidane, MD, MSc, FRCSC, Health Sciences Centre, GE-611, 820 Sherbrook St, Winnipeg, Manitoba, Canada R3A-1R9 (E-mail: bkidane@hsc.mb.ca). J Thorac Cardiovasc Surg 2017;-:1-2 0022-5223/