Colin Schieman

Laparoscopic incisional hernia repair: a review of the literature

Incisional hernia is a common long-term complication of abdominal surgery. Historically the open repair with or without mesh was the mainstay of treatment. However, many recently published laparoscopic repair studies have challenged surgeons to re-evaluate which technique provides the best short and long-term outcomes. A Medline search of all English-language literature was performed using the keywords ‘incisional’, ‘ventral’, ‘hernia’, ‘laparoscopic’, and ‘open’. Further references were obtained by cross-referencing the bibliography in each paper. Current evidence suggests that the laparoscopic incisional hernia repair is the optimal surgical treatment. A laparoscopic repair appears to shorten hospital stay, decrease perioperative complication rates, and decrease recurrence rates. However, there is no randomized trial utilizing a standardized complication grading system making it difficult to draw a definitive conclusion as to which repair is best.

Paraesophageal Hernia: Clinical Presentation, Evaluation, and Management Controversies

Practically, hiatal hernias are divided into sliding hiatal hernias (type I) and PEH (types II, III, or IV). Patients with PEH are usually symptomatic with GERD or obstructive symptoms, such as dysphagia. Rarely, patients present with acute symptoms of hernia incarceration, such as severe epigastric pain and retching. A thorough evaluation includes a complete history and physical examination, chest radiograph, UGI series, esophagogastroscopy, and manometry. These investigations define the patients anatomy, rule out other disease processes, and confirm the diagnosis. Operable symptomatic patients with PEH should be repaired. The underlying surgical principles for successful repair include reduction of hernia contents, removal of the hernia sac, closure of the hiatal defect, and an antireflux procedure. Debate remains whether a transthoracic, transabdominal, or laparoscopic approach is best with good surgical outcomes being reported with all three techniques. Placement of mesh to buttress the hiatal closure is reported to reduce hernia recurrence. Long-term follow-up is required to determine whether the laparoscopic approach with mesh hiatoplasty becomes the procedure of choice.

Does surgeon fatigue influence outcomes after anterior resection for rectal cancer

BACKGROUND The long work hours in surgery may contribute to medical errors and impact patient outcomes. To date, there are no studies investigating outcomes related to fatigue in general surgery. METHODS All patients undergoing anterior resection between 1994 and 2005 at 2 university hospitals were identified. Cases were categorized as fatigued or nonfatigued and then compared with respect to complications and cancer recurrence. RESULTS Two hundred seventy patients underwent anterior resection during the study period. Of these, 22 were performed when the surgeon was fatigued. The fatigued and nonfatigued groups had similar preoperative characteristics. The rates of intraoperative complications (fatigued 14%, rested 18%, P = .58), major postoperative complications (fatigued 9%, rested 15%, P = .68), long-term complications (fatigued 31%, rested 31%, P = .9), and local cancer recurrence rates (fatigued 0%, rested 7%, P = .2) were not significantly different between the 2 groups. CONCLUSIONS Surgeon fatigue did not influence outcomes after anterior resection for rectal cancer.

Thoracic Surgery Training in Canada According to the Residents: The Thoracic Surgery Resident Survey, of the Canadian Thoracic Manpower and Education Study (T-Med)

OBJECTIVE The resident component of the Canadian Thoracic Manpower and Education Study (T-MED) was conducted to understand the basic demographic of Canadian thoracic surgery residents, the factors influencing their selection of training programs, current work conditions, training and competencies, and opinions in regard to the manpower needs for the specialty. DESIGN A modified Delphi process was used to develop a survey applicable to thoracic surgery residents. In May and June 2009, residents completed the voluntary anonymous Internet-based survey. All Canadian residents participated in the survey, providing a 100% response rate. RESULTS Most respondents were male (11/12), and the average age was 34 years old with an anticipated debt greater than

Evidence-Based Medicine: Levels of Evidence and Evaluation Systems

50,000 on graduation. All residents worked more than 70 hours per week, with most doing 1 : 3 or 1 : 4 on-call. Two-thirds of respondents reported being satisfied or very satisfied with their training program. Rates of anticipated competence in performing various thoracic surgeries on graduation differed between residents and program directors. Two-thirds (8/12) of residents planned to practice thoracic surgery exclusively, and hoped to practice in an academic setting. Most residents (10/12) agreed or strongly agreed that not enough jobs are available in Canada for graduating trainees and that the number of residency positions should reflect the predicted availability of jobs. CONCLUSIONS This study has provided detailed information on thoracic surgery resident demographics and training programs. Most thoracic surgery residents are satisfied with their current training program but have concerns about their job prospects on graduation, and they believe that the number of training positions should reflect potential job opportunities. This survey represents the first attempt to characterize the current state of thoracic surgery training in Canada from the residents perspective and may help in directing educational and manpower planning.

Postdischarge venous thromboembolic complications following pulmonary oncologic resection: An underdetected problem

Evidenced-based medicine (EBM) is a philosophic approach to clinical problems introduced in the 1980s by a group of clinicians at McMaster University in Canada with an interest in clinical epidemiology. The concepts associated with EBM have been widely disseminated. While many feel EBM represents a paradigm shift,1,2 others have debated the usefulness of this approach.3

A multicenter review of deep venous thrombosis prophylaxis practice patterns for blunt hepatic trauma

OBJECTIVES To determine the prevalence of delayed postoperative venous thromboembolism (VTE) in patients undergoing oncologic lung resections, despite adherence to current in-hospital VTE prophylaxis guidelines. METHODS Patients undergoing lung resection for malignancy in 2 tertiary-care centers were recruited between June 2013 and December 2014. All patients received guideline-based VTE prophylaxis until hospital discharge. Patients underwent computed tomography chest angiography with pulmonary embolism (PE) protocol and bilateral lower extremity venous Doppler ultrasonography at 30 ± 5 days after surgery to determine the incidence of postoperative VTE. Univariate analysis was used to compare the VTE and non-VTE groups. RESULTS A total of 157 patients were included, 45.9% were men with a mean age of 66.7 years. VTE prevalence was 12.1% with a total of 19 VTE events, including 14 PEs (8.9%), 3 deep venous thromboses (DVTs) (1.9%), 1 combined PE/DVT, and 1 massive left atrial thrombus originating from the pulmonary vein stump after pulmonary lobectomy. PE events occurred in the operated lung 64% of the time and 4 patients (21.1%) were symptomatic at diagnosis. The 30-day mortality rate of VTE events was 5.2%, with 1 patient who died secondary to massive in situ ipsilateral PE following readmission to the hospital. Univariate analysis did not demonstrate significant differences between the VTE and non-VTE populations with regard to baseline characteristics. CONCLUSIONS Despite adherence to in-hospital standard prophylaxis guidelines, VTE events are frequent, often asymptomatic, and with associated significant morbidity and mortality. More research into the potential role of predischarge screening and extended prophylaxis is warranted.

Comprehensive Clinical Staging for Resectable Lung Cancer: Clinicopathological Correlations and the Role of Brain MRI

BackgroundNon-operative management of blunt hepatic trauma is successful in the majority of hemodynamically stable patients. Due to the risk of recurrent hemorrhage, pharmacologic deep venous thrombosis (DVT) prophylaxis is often delayed. The optimal timing of prophylaxis is unclear. A multi-centre, retrospective review of patients with blunt hepatic injuries presenting between 2000 and 2004 was performed. All patients had an ISS ≥ 12 and a CT scan confirming hepatic trauma. Patients were categorized into: (1) early DVT prophylaxis (≤ 48 hrs of admission), (2) delayed prophylaxis (>48 hrs), and (3) no prophylaxis.Methods and resultsThirty-seven (25%) and 45 (42%) patients received early and delayed DVT prophylaxis respectively. The remainder (32%) received none. Mean hepatic injury grades were lower in the early prophylaxis group (II) compared to the delayed and no prophylaxis cohorts (III)(p = 0.002). The number of patients requiring post-admission blood transfusions was highest in the delayed group (44%) compared to the early (26%) and no prophylaxis (6%) groups (p = 0.03). No patient in the early prophylaxis cohort developed a DVT or required delayed angiographic or operative intervention. Two patients in the delayed group failed non-operative management. Eight (18%) patients in the delayed group developed a clinically significant DVT; 1 (2%) progressed to a PE.ConclusionPractice patterns indicate that chemical DVT prophylaxis initiated within 48 hours of admission may be safe in patients with significant blunt hepatic trauma. Delays in prevention result in venothromboembolic events, but not in fewer blood transfusions or a decreased need for subsequent angiographic or operative therapies.

Design of a Consensus-Derived Synoptic Operative Report for Lung Cancer Surgery

Introduction In our model of comprehensive clinical staging (CCS) for lung cancer, patients with a computerized tomography scan of the chest and upper abdomen not showing distant metastases will then routinely undergo whole body positron emission tomography/computerized tomography and magnetic resonance imaging (MRI) of the brain before any therapeutic decision. Our aim was to determine the accuracy of CCS and the value of brain MRI in this population. Methods A retrospective analysis of a prospectively entered database was performed for all patients who underwent lung cancer resection from January 2012 to June 2014. Demographics, clinical and pathological stage (seventh edition of the American Joint Committee on Cancer/Union for International Cancer Control tumor, node, and metastasis staging manual), and costs of staging were collected. Correlation between clinical and pathological stage was determined. Results Of 315 patients with primary lung cancer, 55.6% were female and the mean age was 70 ± 9.6 years. When correlation was analyzed without consideration for substages A and B, 49.8% of patients (158 of 315) were staged accurately, 39.7% (125 of 315) were overstaged, and 10.5% (32 of 315) were understaged. Only 4.7% of patients (15 of 315) underwent surgery without appropriate neoadjuvant treatment. Preoperative brain MRI detected asymptomatic metastases in four of 315 patients (1.3%). At a median postoperative follow‐up of 19 months (range 6–43), symptomatic brain metastases developed in seven additional patients. The total cost of CCS in Canadian dollars was

Can preoperative computed tomography of the chest predict completeness of the major pulmonary fissure at surgery

367,292 over the study period, with