Sean C. Grondin

Treatment of malignant mesothelioma.

Malignant pleural mesothelioma (MPM) is a rare tumor that predominantly afflicts men over 50 years of age. Nearly 3000 MPMs are reported annually in the United States with the incidence expected to rise into the new millenium. Over the past 40 years, MPM has been unequivocally linked to asbestos exposure worldwide. Recently, however, a new theory on the carcinogenesis of this tumor has been proposed with the isolation of a simian virus (SV 40)-like gene sequence in mesothelioma tumor cells. The clinical presentation of MPM is variable, although most patients typically present with dyspnea, chest pain, or pleural effusion. Obtaining a diagnosis of MPM has been greatly assisted by video-assisted surgery and the use of immunohistochemistry and electron microscopic techniques, which help distinguish MPM from other tumor pathologies such as adenocarcinoma. Computed tomography and magnetic resonance imaging have been also useful for determining tumor burden and resectability. Traditionally, strategies for the treatment of MPM have included supportive care, surgery, radiotherapy, and chemotherapy. Survival with supportive care alone ranges between 4 and 12 months. Single-modality therapy using traditional approaches (surgery, radiotherapy, chemotherapy) alone has failed to improve patient survival significantly. Recently, results using a multimodality approach have been favorable. In particular, cytoreductive surgery (pleuropneumonectomy) followed by sequential chemotherapy and radiotherapy have demonstrated improved survival, especially for patients with epithelial histology, negative resection margins, and no metastases to extrapleural lymph nodes. Innovative therapies such as the use of photodynamic, targeted cytokines and gene therapy are currently being investigated for management of MPM.

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.

Clinical statement on the role of the surgeon and surgical issues relating to computed tomography screening programs for lung cancer

Division of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy (GR); Division of Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota (MSA); Division of Thoracic Surgery, New York Presbyterian–Weill Cornell Medical Center, New York, New York (NKA); Division of Thoracic Surgery, National Cancer Institute, Tokyo, Japan (HA); General Thoracic Surgery, Penrose Cardiothoracic Surgery, Colorado Springs, Colorado (MGB); Department of Thoracic Surgery, Yale University, New Haven, Connecticut (FCD); Arkansas Department of Health, Little Rock, Arkansas (CMD); Department of Thoracic Surgery, Institut Mutualiste Montsouris, Paris, France (DG); Division of Thoracic Surgery, Foothills Medical Center, University of Calgary, Calgary, Canada (SCG); Department of Thoracic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts (MTJ); Division of Cardiothoracic Surgery, University of Colorado Denver School of Medicine, Aurora, Colorado (JDM); Sentara Thoracic Surgery Center, Mid-Atlantic Cardiothoracic Surgeons, Ltd, Norfolk, Virginia (JRN); Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Antwerp, Belgium (PEVS); Division of Thoracic Surgery, University of Toronto, Toronto, Canada (TKW); and Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, Washington (DEW)

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 Society of Thoracic Surgeons Expert Consensus Statement: A Tool Kit to Assist Thoracic Surgeons Seeking Privileging to Use New Technology and Perform Advanced Procedures in General Thoracic Surgery

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.

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

Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota; Section of General Thoracic Surgery, University of California, Davis Medical Center, Sacramento, California; Division of Thoracic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Division of Thoracic Surgery, WellStar Health System, Marietta, Georgia; Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Division of Cardiothoracic Surgery, University of Washington, Seattle, Washington; National Cancer Institute, Pascale Foundation, Naples, Italy; Division of Thoracic Surgery, Memorial Hospital-University of Colorado Health, Colorado Springs, Colorado; Department of Surgery, Southern Illinois University, Springfield, Illinois; Division of Thoracic Surgery, NorthShore University Health System, Evanston, Illinois; Esophageal Center of Excellence, Virginia Mason Medical Center, Seattle, Washington; Division of Thoracic Surgery, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Cardiothoracic Surgery, Stanford University, Stanford, California; Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina; Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts; and Division of Thoracic Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada

Evidence-Based Medicine: Levels of Evidence and Evaluation Systems

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.

The role of peri‐hepatic drain placement in liver surgery: a prospective analysis

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

Evidence-Based Medicine: Levels of Evidence and Grades of Recommendation

BACKGROUND The standard use of an intra-operative perihepatic drain (IPD) in liver surgery is controversial and mainly supported by retrospective data. The aim of this study was to evaluate the role of IPD in liver surgery. METHODS All patients included in a previous, randomized trial were analysed to determine the association between IPD placement, post-operative complications (PC) and treatment. A multivariate analysis identified predictive factors of PC. RESULTS One hundred and ninety-nine patients were included in the final analysis of which 114 (57%) had colorectal liver metastases. IPD (n = 87, 44%) was associated with pre-operative biliary instrumentation (P = 0.023), intra-operative bleeding (P < 0.011), Pringles manoeuver(P < 0.001) and extent of resection (P = 0.001). Seventy-seven (39%) patients had a PC, which was associated with pre-operative biliary instrumentation (P = 0.048), extent of resection (P = 0.002) and a blood transfusion (P = 0.001). Patients with IPD had a higher rate of high-grade PC (25% versus 12%, P = 0.008). Nineteen patients (9.5%) developed a post-operative collection [IPD (n = 10, 11.5%) vs. no drains (n = 9, 8%), P = 0.470]. Seven (8%) patients treated with and 9(8%) without a IPD needed a second drain after surgery, P = 1. Resection of ≥3 segments was the only independent factor associated with PC [odds ratio (OR) = 2, P = 0.025, 95% confidence interval (CI) 1.1-3.7]. DISCUSSION In spite of preferential IPD use in patients with more complex tumours/resections, IPD did not decrease the rate of PC, collections and the need for a percutaneous post-operative drain. IPD should be reserved for exceptional circumstances in liver surgery.

To drain or not to drain? Predictors of tube thoracostomy insertion and outcomes associated with drainage of traumatic hemothoraces.

Evidenced-based medicine (EMB) is a philosophical approach to clinical problems introduced in the 1980s by a group of clinicians with an interest in clinical epidemiology at McMaster University in Canada. The concepts associated with this approach have been widely disseminated and described by many as a paradigm shift. Others, however, have debated the usefulness of this approach.