Janet P. Edwards

Wound Protectors Reduce Surgical Site Infection A Meta-Analysis of Randomized Controlled Trials

Objective: A meta-analysis of randomized clinical trials (RCTs) was conducted to evaluate whether wound protectors reduce the risk of surgical site infection (SSI) after gastrointestinal and biliary tract surgery. Background: The effectiveness of impervious wound edge protectors for reduction of SSI remains unclear. Methods: A systematic review was conducted in Medline, EMBASE, and the Cochrane Library to identify RCTs that evaluate the risk of SSI after gastrointestinal and biliary surgeries with and without the use of an impervious wound protector. The pooled risk ratio was estimated with random-effect meta-analysis. Sensitivity analyses were performed to examine the impact of structural design of wound protector, publication year, study quality, inclusion of emergent surgeries, preoperative antibiotic administration, and bowel preparation on the pooled risk of SSI. Results: Of the 347 studies identified, 6 RCTs representing 1008 patients were included. The use of a wound protector was associated with a significant decrease in SSI (RR = 0.55, 95% CI 0.31–0.98, P = 0.04). There was a nonsignificant trend toward greater protective effect in studies using a dual ring protector (RR = 0.31, 95% CI 0.14–0.67, P = 0.003), rather than a single ring protector (RR = 0.83, 95% CI 0.38–1.83, P = 0.64). Publication year (P = 0.03) and blinding of outcome assessors (P = 0.04) significantly modified the effect of wound protectors on SSI. Conclusions: Our results suggest that wound protectors reduce rates of SSI after gastrointestinal and biliary surgery.

Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability

OBJECTIVES Postintubation hemodynamic instability (PIHI) is a potentially life-threatening adverse event of emergent endotracheal intubation. The objectives of this study were to determine the incidence, risk factors, and impact on patient outcomes associated with PIHI in intubations performed in emergency medicine. METHODS A structured chart audit was performed of all consecutive adult patients requiring emergent endotracheal intubations over a 16-month period at a tertiary care emergency department (ED). Data collection included medications, comorbidities, vital signs in the 30 minutes before and after intubation, hospital length of stay, and in-hospital mortality. PIHI was defined as a decrease in systolic blood pressure (SBP) to ≤ 90 mm Hg, a decrease in SBP of ≥ 20% from baseline, a decrease in mean arterial pressure to ≤ 65 mm Hg, or the initiation of any vasopressor medication at any time in the 30 minutes following intubation. RESULTS Overall, 218 patients intubated in the ED were identified, and 44% (96 of 218) developed PIHI. On multivariate analysis, increasing age (OR 1.03, 95% CI 1.01-1.05), chronic obstructive pulmonary disease (OR 3.00, CI 1.19-7.57), and pre-emergent endotracheal intubation hemodynamic instability (OR 2.52, 95% CI 1.27-4.99) were associated with the development of PIHI. The use of a neuromuscular blocking medication was associated with a decreased incidence of PIHI (OR 0.34, 95% CI 0.16-0.75). CONCLUSIONS Based on our data, postintubation hypotension occurs in a significant proportion of ED patients requiring emergent airway control. Further investigation is needed to confirm the factors we found to be associated with PIHI and to determine if PIHI is associated with increased morbidity and mortality.

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

The Impact of Computed Tomographic Screening for Lung Cancer on the Thoracic Surgery Workforce

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.

A rare cavernous hemangioma of the adrenal gland

BACKGROUND This study aimed to predict variation in the thoracic surgery workforce requirements with the introduction of a national chest computed tomographic (CT) screening program for individuals at high risk of lung cancer. METHODS Using Canadian census microdata and the Canadian Community Health Survey, a microsimulation model representing the national population was developed. The demand component simulates the incidence of lung cancer, whereas the supply component simulates the number of practicing thoracic surgeons. A national CT screening program in high-risk individuals (>30 pack-year history of smoking; age, 55-74 years) was introduced into the model to predict changes in the number of operable lung cancers per thoracic surgeon. RESULTS From 2013 to 2040, the Canadian population increased from 34 to 43 million. The number eligible for screening varies from 1,112,800 (2013) to 513,200 (2040), peaking at 1,147,700 (2017). Comparing CT screening with chest radiography, overall lung cancer diagnoses increase 7.3% by 2040, with stage 1A increasing by 15.6% and stage IV decreasing by 7.5%. The rate of operable early lung cancers per thoracic surgeon increases by 24.2% (2020), 19.8% (2030), and 16% (2040), with CT screening relative to the baseline increase seen with chest radiography. CONCLUSIONS With the implementation of a CT screening program there will be an increase in operable lung cancers, resulting in increased surgical volume. A national strategy for the thoracic surgery workforce is necessary to ensure that an appropriate number of surgeons are being trained to meet the future needs of the national population.

A novel approach for the accurate prediction of thoracic surgery workforce requirements in Canada

INTRODUCTION Cavernous hemangiomas of the adrenal gland are rare. We report a case of a cavernous hemangioma of the adrenal gland presenting as an adrenal incidentaloma suspicious for adrenal cortical carcinoma (ACC). PRESENTATION OF CASE A 78 year old woman was admitted after a fall. Abdominal computed tomography revealed a large right adrenal lesion with features suspicious for adrenal cortical carcinoma (5.4 cm × 3.3 cm, unilateral, tumor calcifications, average Hounsfield units 55). The tumor was removed intact by a laparoscopic approach and pathology revealed a cavernous hemangioma of the adrenal gland. DISCUSSION Adrenal incidentalomas are found in up to 10% of patients undergoing abdominal imaging. Differential diagnosis includes both benign and malignant lesions. Guidelines for removal of adrenal incidentalomas recommend surgery based on functional status, size, and presence of concerning features on diagnostic imaging. Cavernous hemangiomas are rare, benign vascular malformations which can be challenging to distinguish pre-operatively from malignant lesions such as ACC. CONCLUSION Cavernous hemangiomas of the adrenal gland are exceedingly rare. These benign tumors have imaging features which may be suggestive of adrenal cortical carcinoma. The treatment of choice is surgical excision due the difficulty of excluding malignancy.

Forecasting the impact of stereotactic ablative radiotherapy for early-stage lung cancer on the thoracic surgery workforce

OBJECTIVE To develop a microsimulation model of thoracic surgery workforce supply and demand to forecast future labor requirements. METHODS The Canadian Community Health Survey and Canadian Census data were used to develop a microsimulation model. The demand component simulated the incidence of lung cancer; the supply component simulated the number of practicing thoracic surgeons. The full model predicted the rate of operable lung cancers per surgeon according to varying numbers of graduates per year. RESULTS From 2011 to 2030, the Canadian national population will increase by 10 million. The lung cancer incidence rates will increase until 2030, then plateau and decline. The rate will vary by region (12.5% in Western Canada, 37.2% in Eastern Canada) and will be less pronounced in major cities (10.3%). Minor fluctuations in the yearly thoracic surgery graduation rates (range, 4-8) will dramatically affect the future number of practicing surgeons (range, 116-215). The rate of operable lung cancer varies from 35.0 to 64.9 cases per surgeon annually. Training 8 surgeons annually would maintain the current rate of operable lung cancer cases per surgeon per year (range, 32-36). However, this increased rate of training will outpace the lung cancer incidence after 2030. CONCLUSIONS At the current rate of training, the incidence of operable lung cancer will increase until 2030 and then plateau and decline. The increase will outstrip the supply of thoracic surgeons, but the decline after 2030 will translate into an excess future supply. Minor increases in the rate of training in response to short-term needs could be problematic in the longer term. Unregulated workforce changes should, therefore, be approached with care.

Has the quality of reporting of randomized controlled trials in thoracic surgery improved

OBJECTIVES To predict variation in thoracic surgery workforce requirements with the introduction of stereotactic ablative radiotherapy (SABR) for the treatment of early-stage non-small-cell lung cancer (NSCLC). METHODS Using Canadian census microdata and the Canadian Community Health Survey, a microsimulation model representing the national population was developed. The demand component simulates the incidence of lung cancer, incorporating the impact of computed tomography (CT) screening for high-risk individuals (>30 pack-year smoking history; age 55-74 years). The supply component simulates the number of thoracic surgeons. SABR was introduced into the model to predict changes in the number of operable NSCLC cases per thoracic surgeon, modelling 30, 60 and 90% compliance with SABR for Stage IA and then for both Stage IA and IB NSCLC. RESULTS In the absence of SABR, the volume of operative NSCLC per surgeon increases by a peak of 49.4% (by 2027) and then gradually declines to the present day volume by 2049. More dramatic decreases are seen with increasing compliance with SABR for Stage IA/IB NSCLCs. If the number of new surgeons entering the workforce per year were reduced by 33%, the operative volume per surgeon would increase by a peak of 57.1% (30% Stage IA SABR compliance) and would decrease by up to 49.1% (90% Stage IA SABR compliance). CONCLUSIONS With the implementation of SABR for treatment of early NSCLC, there would be a decrease in operative volume. The impact would depend on the stage of NSCLC for which SABR is recommended and on compliance. A national strategy for thoracic surgery workforce planning is necessary, given the complex interaction of CT screening and the treatment of medically operable early NSCLC with SABR.

Meta-analytic comparison of randomized and nonrandomized studies of breast cancer surgery

OBJECTIVES To evaluate the quality of reporting of randomized controlled trials (RCTs) in the thoracic surgery literature according to Consolidated Standard for Reporting of Trials (CONSORT) and to determine predictors of quality. METHODS All RCTs published in four principal journals between 1998 and 2013 were identified in PubMed. Two independent reviewers assessed each trial using the CONSORT checklist (1996) with discrepancies resolved by a third reviewer. Mean checklist scores were compared between trials published from 1998 to 2005 and 2006 to 2013. The κ statistic for inter-rater agreement was calculated. Stepwise multivariable linear regression was then performed to identify independent predictors of quality. RESULTS After 2 rounds of review, 203 of the 2838 identified articles met inclusion criteria. The overall κ coefficient was 0.95 indicating very good agreement between reviewers. The mean CONSORT score was significantly higher in 2006-13 [mean 10.8; 95% confidence interval (CI): 10.3-11.2] than in 1998-2005 (mean 9.3; 95% CI: 8.7-9.6). On multivariable analysis, there was strong evidence of an increased mean CONSORT score in studies comparing non-surgical interventions, multicentre trials, publications after 2006, studies with increased number of authors and studies funded by industries. CONCLUSIONS Our study suggests that the quality of reporting in the thoracic surgery literature is improving with time and is predicted by factors including number of authors, multicentre trials, type of comparison, time period of publication and industry sponsorship. Ongoing efforts should be made to improve the quality of reporting in thoracic surgery.