Joanne C. Clifton

Thoracoscopic versus laparoscopic modified Heller Myotomy for achalasia: efficacy and safety in 87 patients.

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 < 0.01). One esophageal perforation occurred in each subgroup. A similar analysis in the first 12 THM patients compared with the most recent 12 revealed no significant improvement in OR times or LOS. Three esophageal perforations occurred in the latter subgroup only. All patients had preoperative daily dysphagia to solids. Followup data for LHM (n = 49) (median 17 months, range 1 to 39 months) and THM (n = 15) (median 42 months, range 1 to 69 months) revealed no or minimal dysphagia in 90% (44 of 49) after LHM and 31% (4 of 13) after THM (p < 0.01). No or minimal heartburn was present in 89% (41 of 46) after LHM and 67% (8 of 12) after THM (p < 0.05). Regurgitation was absent or minimal in 94% (46 of 49) after LHM and 86% (12 of 14) after THM (p = 0.3). 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.

Empyema: An Increasing Concern in Canada

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; P<0.001), as did empyema of unknown cause (IRR 1.29, 95% CI 1.08 to 1.54; P=0.005), while surgical empyema did not appear to increase (IRR 1.17, 95% CI 0.97 to 1.43; P=0.114). A Poisson regression showed an increase in the indirect age-standardized IRR during the study period (IRR 1.025, 95% CI 1.018 to 1.032; P<0.001). The IRR for patients younger than 19 years of age from 1995 to 2003 was 2.20 (95% CI 1.56 to 3.10), while the IRR in patients older than 19 years was 1.23 (95% CI 1.14 to 1.34). CONCLUSIONS 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.

Lung Nodules: CT-guided Placement of Microcoils to Direct Video-assisted Thoracoscopic Surgical Resection

PURPOSE 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSION 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.

Peripheral Lung Nodules: Fluoroscopically Guided Video-Assisted Thoracoscopic Resection After Computed Tomography-Guided Localization Using Platinum Microcoils

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 CT-guided 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.

Laparoscopic Esophageal Myotomy and Anterior Partial Fundoplication for the Treatment of Achalasia

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.

Factors associated with postoperative symptoms after laparoscopic Heller myotomy.

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.

A change in clinical practice: a partially stapled cervical esophagogastric anastomosis reduces morbidity and improves functional outcome after esophagectomy for cancer

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 Students 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.

CT-Directed Microcoil Localization of Small Peripheral Lung Nodules: A Feasibility Study in Pigs

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.

The use of thoracoscopy to enhance medical students' interest and understanding of thoracic anatomy

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 videos 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.

Quality-of-Life Measurement in Surgical Randomized Controlled Trials

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.