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INHIBITION OF SELECTIN-SIALYL LEWIS X BINDING REDUCES INFLAMMATION FACILITATED LUNG CANCER CELL ADHERENCE TO HEPATIC SINUSOIDS. J. Spicer, B. McDonald, J. Bernier, B. Giannias, P. Brodt, L.E. Ferri. LD MacLean Surgical Research Laboratories, Division of Thoracic Surgery, McGill University, Montréal, Que.
Lung cancer is associated with poor long-term survival due to a high rate of metastases. There is emerging evidence that increased inflammation might increase the risk of cancer recurrence after resection. Given that selectins have been shown to impact cancer cell adhesion to endothelial cells (EC) in vitro, and that systemic inflammation is known to increase sinusoid EC E-selectin expression, we sought to investigate the influence of inflammation-mediated changes in selectin-sialyl Lewis X binding on the early stages of lung cancer metastasis.
C57BL/6 mice were prepared for hepatic intravital microscopy and injected with highly metastatic Lewis lung carcinoma cells (C10 + GFP) or nonmetastatic Lewis lung carcinoma (C36 + GFP) as a negative control. Both neutrophil (PMN) and cancer cell–EC interactions were quantified with direct in vivo visualization of hepatic microvasculature. In some mice, nonspecific selectin antagonist (fucoidin) or blocking mAb to E-selectin or its ligand sialyl Lewis X (sLex) was administered. To examine the impact of systemic inflammation on PMN and lung cancer cell migration, lipopolysaccharide (LPS) was injected intravenously with and without prior PMN depletion with antineutrophil serum (RB6–8C5). At least 5 mice/condition were prepared. Data are expressed as mean (and standard error of the mean [SEM]). The Mann–Whitney U test determined significance: *p < 0.05, **v. C10 + LPS; ***v. C10 + LPS + PMN depletion.
Compared with control C36, C10 had increased in vivo adherence to sinusoidal EC (mean cells/field of view: 1 [SEM 0.2] v. 13 [SEM 0.5]).* This increased adhesion (13 [SEM 0.5]) was attenuated by fucoidin (6.2 [SEM 0.4])* and blocking mAb to sLex (5.2 [SEM 0.2])* and E-selectin (8.4 [SEM 0.4]).* Systemic inflammation mediated by LPS IV increased neutrophil adherence in the hepatic sinusoidal capillaries 8-fold. This was associated with an increased C10 adherence to the liver, an effect that was limited by sLex blockade, fucoidin and neutrophil depletion (RB6–8C5) (see figure). Blockade of sLex in PMN-depleted mice further diminished C10 adhesion, implying a neutrophil-independent, selectin-mediated mode of cancer cell–EC adhesion.
Using a physiologically relevant in vivo model of the early steps of cancer metastasis, we have demonstrated that selectin-sLex–mediated binding increases the ability of lung cancer cells to adhere to liver sinusoid endothelial cells and that systemic inflammation increases cancer cell adhesion by both neutrophil dependent and independent mechanisms. These data identify the cytokine inducible selectin-sLex axis as a potential target for the treatment of lung cancer.
FIG. 1, abstract 62. Cell adhesion in sinusoids of mice administered metastatic Lewis lung carcinoma cells (C10), lipopolysaccharide (LPS), anti-sLex (sialyl Lewis X antibody), fucoidin and neutrophil (PMS), alone and in combination, with and without prior depletion.
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SURGICAL MANAGEMENT OF PERICARDIAL EFFUSION: COMPARISON OF RESULTS IN PATIENTS WITH MALIGNANT AND NONMALIGNANT DISEASE. O. Nguyen, D. Ouellette. Department of Surgery, Maisonneuve-Rosemont Hospital, University of Montreal, Montréal, Que.
The goal of this presentation is to compare the survival rates between patients with malignant and benign pericardial effusion treated surgically with a subxiphoid pericardial window.
We reviewed the chart of 65 patients between February 1994 and July 2007, all of them treated at a single institution with a subxiphoid pericardial window.
All 65 patients had a pericardial effusion confirmed by echocardiography. Forty-five of these patients had initial drainage by pericardiocentesis. Among these 45 patients, a pericardial catheter was left in place in 35 patients. Among the patients who had cancer, the majority had lung cancer (69%). The overall complication rate was 26%. The overall 30-day mortality was 23%. It was, respectively, 27% and 7% for malignant pericardial effusion and benign pericardial effusion. The survival rates at 3 months, 6 months, 1 year and 2 years for patients with cancer were 47%, 29%, 20% and 10%, respectively. For noncancer patients, the survival rates at 3 months, 6 months, 1 year and 2 years were 93%, 93%, 86% and 86%, respectively. The median survival time for patients with cancer was 3 months and for patients without cancer was 84 months.
Patients with malignant disease had a worse survival rate than patients with nonmalignant disease. Among cancer patients, lung cancer patients fared worse. The subxiphoid pericardial window is a simple, safe and effective surgical procedure. However, the use of any surgical approach in patients with advanced malignant disease should be individualized, and the benefits and risks of surgery should be clearly explained to patients, their family and the referring physician.
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MANAGEMENT AND OUTCOMES OF TRAUMATIC TRACHEAL INJURY. W.C. Hanna, L.E. Ferri, T. Razek, D.S. Mulder. Divisions of Thoracic Surgery and Trauma, McGill University Health Centre, Montréal, Que.
Traumatic tracheal injury (TTI) is a rare consequence of penetrating neck wounds and, as such, the optimal treatment is unclear. We sought to define the characteristics and management of this complicated condition.
A prospectively entered trauma registry from a busy level 1 centre was reviewed for all cases of TTI from 1993 and 2007. Data were collected on patient characteristics, patterns of injury, investigations, management and outcomes.
The incidence of TTI was 0.05%/year and resulted in 12 patients (all male). Stab wounds to the neck constituted 75% (9/12) of injuries. Associated injuries included esophagus (2/12), thyroid (3/12), carotid artery (2/12) and larynx (1/12). Presenting signs included subcutaneous emphysema (7/12), pneumothorax (4/12), air leak from wound (4/12) and pneumomediastinum (3/13). Ten patients underwent preoperative investigations: chest radiography (10/10), computed tomography (4/10) and bronchoscopy (2/10). All cases were managed operatively via cervical incision (10/12) or thoracotomy (2/12). The trachea was repaired primarily in 10 of 12 cases. Concomitant esophageal repair with a muscle flap was done in 2 cases. A muscle patch without primary repair was used in 1 case, and no repair was attempted in 1 of 12 cases. There were no mortalities, and median length of hospital stay was 8 (1–48) days.
This descriptive study demonstrates that for patients arriving alive to a level 1 trauma centre with a traumatic tracheal injury, proper and timely operative management provides excellent outcomes.
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THE USE OF THORACOSCOPY TO IMPROVE MEDICAL STUDENTS' INTEREST AND UNDERSTANDING OF THORACIC ANATOMY: A PILOT STUDY. S. Alnassar, J. Clifton, R.J. Finley, R. Sidhu. Department of Surgery, University of British Columbia, Vancouver, BC.
The evolution of minimally invasive surgery (MIS) has a great potential for improving both health care and medical education. MIS thoracoscopy can be a useful teaching tool offering a link between clinical medicine and basic science. Our objective was to develop a video-based educational tool designed for learning thoracic anatomy and to examine whether this tool would increase students' stimulation and motivation for learning anatomy.
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 which demonstrated live anatomy of the thorax (15 min) and then asked to complete a 5-point Likert-type questionnaire assessing the video's usefulness.
Questionnaires were completed by 119 medical students. Most students were satisfied with the thoracoscopic video as a teaching tool (mean score 4.39, standard deviation [SD] 0.65) and thought that it increased their interest in learning (mean score 4.63, SD 0.58) and their understanding of thoracic anatomy (4.10, SD 0.89). The majority would like to see this new teaching tool implemented into the anatomy curriculum (mean score 4.60, SD 0.66). The video presentation also increased students interest in surgery as a future career (mean score 4.19, SD 0.83).
Incorporating live surgery via 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. Future studies will include a randomized controlled trial to evaluate the objective gain in knowledge associated with this teaching tool.
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THE EVALUATION OF THORACIC TRAUMA IN STABLE PATIENTS USING A ROBOTIC TELESURGICAL MODEL: A FEASIBILITY STUDY. P.D. Bhatia, D. Bottoni, R.A. Malthaner. Canadian Surgical Technologies & Advanced Robotics (CSTAR), Lawson Health Research Institute, Department of Surgery, Division of Thoracic Surgery, University of Western Ontario, London, Ont.
The feasibility of using a robotic telesurgical platform to manage thoracic trauma in stable patients was evaluated in an animal model.
Experiments were conducted on a total of 10 porcine hemithoraces (5 left and 5 right). Injuries (lung laceration, massive hemothorax, diaphragmatic laceration, aortic hematoma) were generated in a random, blinded fashion in the hemithorax using a minimally invasive technique. The da Vinci surgical telemanipulator (Intuitive Inc.) was used to evaluate and manage the injuries inflicted on each hemithorax. Primary outcomes were time to survey, number of injuries correctly identified and time to successfully repair each injury. Secondary outcomes included number of iatrogenic injuries incurred, subjective evaluation of the process by the operating surgeon and mortality of the animal at the end of the experiment.
Ninety-five percent of injuries (19/20) were correctly identified. The median survey time was 20.5 (range 17–68) minutes. A significant learning curve was demonstrated with survey times. The mean time to repair lung lacerations was 19.8 (range 11.5–30.5) minutes. The mean evacuation time for hemothoraces was 5.25 (range 3–6.5) minutes. Diaphragmatic lacerations were initially difficult to access and repair and required repositioning of the ports and the robot. Only 2 out of 5 lacerations successfully repaired (mean time to repair 38.8, range 37–40.5 minutes). Aortic injuries were identified but not repaired. One subject (10%) died of respiratory failure due to a pre-existing pneumonia.
A robotic telesurgical approach to the evaluation of stable thoracic trauma patients is safe and feasible in a porcine model. Diaphragmatic injuries can be repaired but require repositioning of the robot. Further advances in flexible instruments and less bulky robotic platforms may make this concept applicable to human patients in the future.
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ROLE OF INTRAPLEURAL TISSUE PLASMINOGEN ACTIVATOR AND STREPTOKINASE IN MANAGEMENT OF COMPLICATED PLEURAL EFFUSIONS. S. Alghamdi, D. AlShehab, G.P. Giraldo, R.S. Sundaresan, D.E. Maziak, F.M. Shamji, A.J.E. Seely. Department of Thoracic Surgery, The Ottawa Hospital, Ottawa, Ont.
Intrapleural fibrinolysis remains a controversial therapy for complicated pleural effusions. Our aim was to evaluate safety and efficacy of intrapleural fibrinolysis in a single institution experience.
Over a 3-year period (2004–2007), 61 consecutive patients (age 18–88 years; 46 [75%] male, 15 [25%] female) received intrapleural fibrinolysis for complicated pleural effusions related to infection (n = 44 secondary to bacterial pneumonia: 37 tuberculosis, 1 postoperative, 5 post-trauma, 1 infection), malignancy (n = 8: 4 lung cancer, 4 other malignancies), hemothorax all related to blunt trauma (n = 3) and unknown etiology (n = 6). Indications for intrapleural fibrinolysis were persistent radiological evidence of loculations after failing drainage by tube thoracostomy, and included intrapleural tissue plasminogen activator (TPA; n = 39, 64%) or streptokinase (n = 22, 36%) as a daily dose of 16 mg and 250 000 units in 100 mL normal saline via pleural tube, respectively. Patients were treated for 1–6 days (mean 3, standard deviation [SD] 1.4); 13 patients (21%) received 2 cycles (6 d) of fibrinolytics. Once clinical and radiological reevaluation confirmed minimal drainage (< 150 mL/24 h), and resolving empyema and effusion, the chest tube or pigtail was removed. Failure of treatment (i.e., inadequate lung re-expansion) or clinical deterioration (i.e., sepsis syndrome) mandated surgical intervention.
Following intrapleural fibrinolysis, clinical improvement occurred in 47 patients (77%) and failure requiring surgery in 14 patients (23%): 12 (86%) thoracotomy, decortication and 2 (14%) thoracoscopic pleural drainage. The mean length of stay was 11 (SD 8) days. No significant differences were noted between streptokinase and TPA regarding fluid drained or hospital length of stay. One patient on anticoagulants experienced a complication from bleeding. There was 1 mortality (1.6%) from multiple organ failure secondary to refractory pseudomonas pneumonia 4 months postintrapleural streptokinase.
Intrapleural administration of tissue plasminogen activator or streptokinase is an effective and safe mode of treatment for complicated pleural effusions and may decrease the need for operative intervention.
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VATS LOBECTOMY IS ASSOCIATED WITH IMPROVED SHORT-TERM OUTCOMES COMPARED WITH THE OPEN APPROACH. W. Saleh, C. Robineau, L.S. Feldman, C. Sirois, D.S. Mulder, L.E. Ferri. Divisions of Thoracic and General Surgery, McGill University, Montréal, Que.
Barriers to widespread adoption of minimally invasive approaches to pulmonary lobectomy include a lack of data documenting superiority to the conventional open approach. We thus examined our early experience of video-assisted thoracoscopic surgical (VATS) lobectomy and compared the short-term outcomes of this procedure to open lobectomies performed during the same time period.
All patients undergoing lobectomy at a single institution from January 2006 to December 2007 were identified from a prospective database. In order to reduce selection bias, patients undergoing VATS lobectomy were compared with open lobectomy patients who were potentially VATS operable (e.g., t < 4 cm, noncentral). Patient characteristics, operative variables and postoperative outcomes were compared between the 2 study groups. Data are expressed as median (range) or mean (standard deviation [SD]). The Mann–Whitney U test and the Fisher exact test determined significance (p < 0.05). Multivariate analysis identified significant predictors of length of stay (LOS).
Of 124 patients undergoing lobectomy, 35 were excluded (reason = t > 4 cm, bilobectomy, sleeve/chest wall resection or hilar nodal disease) leaving in 69 open (O) and 20 VATS (V). There was no difference in age (V = 69 [35–82] y v. O = 66.5 [25–84] y), sex (V = 57% male v. O = 55% male), American Society of Anesthesiologists (ASA) grade> 2 (V = 3/20 v. O = 15/69), predicted FEV1 (V = 87% [SD 15%] v. O = 88% [SD 17%]) or size of tumour (V = 2 [0.5–3.5] cm v. O = 2.3 [0.5–4] cm). Surgical time (V = 162 [SD 48] min v. O = 122 [SD 44] min),* but not total operating room time (V = 230 [SD 67] min v. O = 198 [SD 59] min), was higher in VATS. A trend for reduced prolonged air leak (V = 0/20 v. O = 9/69, p = 0.08), all pulmonary complications (V = 1/20 v. 14/69, p = 0.09) and all complications (V = 2/20 v. O = 20/69, p = 0.06) was seen with VATS. VATS was associated with shorter duration of chest tube drainage (V = 1.5 [1–6] d v. O = 6 [2–30] d)* and LOS (V = 2.5 [1–7] d v. O = 6 [3–50] d).* Linear regression identified tumour size (p = 0.01) and operative approach (p = 0.04) as independent predictors of LOS.
VATS lobectomy is safe for resection of early lung cancer and compares favourably to open lobectomy with respect to short-term postoperative outcomes. Prospective studies to compare the long-term outcome between the 2 approaches are needed.
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TRACHEAL AND LARYNGOTRACHEAL RESECTIONS: A SINGLE INSTITUTIONAL 18-YEAR EXPERIENCE. S. Al-Mutairy, H. Unruh, L. Tan, P. Kerr. Departments of Surgery and Otolaryngology, University of Manitoba, Winnipeg, Man.
Tracheal resections are uncommon in most surgical practices. Our present understanding of the principles of tracheal surgery owes much to the efforts Dr. Hermes C. Grillo and colleagues from Harvard Medical School and Dr. F. Griffith Pearson and colleagues from the University of Toronto. Beginning in 1995, we undertook a joint effort with the Department of Otolaryngology whereby all patients were operated on by a team that included both a thoracic surgeon and an otolaryngologist. Our approach has been to establish a widely patent airway with a temporary tracheotomy. If required, this included intralaryngeal resection of the stenosis. Nineteen patients had tracheal resection, 8 with postintubation stenosis (PIS), 8 with idiopathic subglottic stenosis (ISS) and 3 with primary tracheal tumours. Two patients in the PIS group required standard larnygotracheal resection and tracheostomy, while the rest were managed with simple tracheal resection and apposition. Six patients in the ISS group required laryngotracheal resection of whom 5 had intralaryngeal resection of the stenosis. This latter procedure was accomplished by elevation of the mucosa from the posterior plate of the cricoid after the anterior aspect of the ring had been resected. A high-speed burr was used to thin the plate to a thickness of about 1 mm, taking care to not perforate the plate. The elevated mucosa was thinned of the abnormal submucosal tissue, and with anastomosis the thinned posterior cricoid was covered with laryngeal mucosa. All had a temporary tracheotomy placed below the repair. Only 2 suprahyoid release manoeuvres were required, 1 each in the PIS and ISS groups. All patients were successfully decannulated, usually at 1 month following surgery. One patient had a stricture which was managed successfully by simple dilatation. No other airway complications, including recurrent nerve palsy, were observed.
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THE ROLE OF ENDOBRONCHIAL ULTRASOUND (EBUS-TBNA) IN LYMPH NODE STAGING OF NON-SMALL-CELL LUNG CANCER. M.F. Humer, W. Senner, A. Luoma, B. Nelems. Interior Health Authority Thoracic Surgery Programme, Kelowna, BC.
This study was designed to define the role of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in staging non-small-cell lung cancer (NSCLC), comparing EBUS to mediastinoscopy. Between January 15, 2007, and January 15, 2008, 307 patients underwent EBUS, 198 with NSCLC.
Of 198 NSCLC patients, 182 had concurrent EBUS and mediastinoscopy nodal biopsies, 16 patients had EBUS only because of comorbidity, complexity. Of the 182 patients, within the zone reachable by both mediastinoscopy and EBUS, 156 patients had direct correlation: 119 mediastinoscopy and EBUS biopsies were both negative; in 37 cases they were both positive. Of the 26 cases without direct correlation, 14 were within the combined reachable zone: 5 mediastinoscopy cases were negative, EBUS-positive ‚mediastinoscopy miss' and 9 EBUS cases were negative and mediastinoscopy-positive ‚EBUS miss' false negatives. Twelve cases without direct correlation were in the EBUS extended zone not reachable by mediastinoscopy. In this extended zone, 8 EBUS cases were positive in the posterior subcarinal 7 position, mediastinoscopy being negative. This posterior subcarinal 7 biopsy is mediastinoscopy's traditional ‚blind spot.' In the extended zone, 4 EBUS cases were positive in the interlobar 11 position.
Combining mediastinoscopy and EBUS is more accurate than either procedure alone. EBUS provides additional information in the extended nonmediastinoscopy zone of posterior subcarina and interlobar positions. We recommend EBUS to precede mediastinoscopy with large mediastinal nodes, followed by mediastinoscopy if EBUS negative. In potentially resectable cases with small mediastinal nodes on computed tomography, we recommend concurrent EBUS and mediastinoscopy, a new gold standard.
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TRANSLYMPHATIC CHEMOTHERAPY FOR THE TREATMENT OF LYMPHATIC METASTASIS IN LUNG CANCER. J. Liu, X.Y. Wu, M.R. Johnston. Institute of Medical Science, Faculty of Medicine, Department of Pharmaceutical Science, Faculty of Pharmacy, University of Toronto, Toronto, Ont., Division of Thoracic Surgery, Dalhousie University, Halifax, NS.
We developed an implantable drug delivery system for the treatment of lymphatic metastasis in lung cancer. Biodegradable polylactide-co-glycolide microspheres containing paclitaxel (PLGA-PTX) with drug loading of 7% (w/w) were formulated and then incorporated into a gelatin sponge matrix. The device is designed to be placed into the pleural space in proximity to the mediastinal lymphatics during lung cancer surgery. The system was characterized in vitro. Pharmacokinetics were studied in rats and compared with a similar dose of paclitaxel (Taxol, 8 mg/kg) given intravenously (iv) and intrapleurally (ipl). PTX concentrations in lymph nodes and plasma were determined by liquid chromatography mass spectrometry. The area under the concentration-time curve (AUC) was calculated. Therapeutic efficacy was assessed in a nude rat orthotopic lung cancer model with lung tumour resection 14 days after tumour implantation. Animals were treated intraoperatively with either intrapleural placement of PLGA-PTX sponge (100 mg/kg), placebo sponge or no treatment. Tumour recurrences were examined 32 days after implantation. In vitro, the PLGA-PTX gelatin sponge system exhibited controlled release properties. The microspheres were selectively taken up by pleural lymphatics and delivered to regional lymph nodes as the gelatin matrix disintegrated in the pleural cavity. Pharmacokinetic studies revealed a significantly higher AUC in mediastinal lymph nodes with ipl placement of the PLGA-PTX sponge as compared with iv or ipl administration of paclitaxil. This represents a 100- to 400-fold increase in lymphatic drug exposure as compared with iv dosing. Peak plasma concentration with the PLGA-PTX sponge was significantly less than iv drug administration. In the tumour-bearing rats, there was an 80% reduction in lymph node metastasis as compared with controls. Translymphatic targeted drug delivery reduces lymph node metastasis in this preclinical lung cancer model. This effect may be attributed to the improved pharmacokinetic distribution of PTX to the mediastinal lymphatic system.
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ROBOT-ASSISTED PALPATION IMPROVES MINIMALLY INVASIVE TUMOUR LOCALIZATION. A.L. Trejos, J. Jayender, M.T. Perri, M.D. Naish, R.V. Patel and R.A. Malthaner. Canadian Surgical Technologies & Advanced Robotics (CSTAR), Lawson Health Research Institute, Departments of Electrical and Computer Engineering and Mechanical and Materials Engineering, Division of Thoracic Surgery, University of Western Ontario, London, Ont.
Localizing hidden tumours during minimally invasive surgery (MIS) such as video-assisted thoracoscopic surgery (VATS) can be challenging. A tactile sensing instrument (TSI) that uses a commercially available sensor to measure distributed pressure profiles along the contacting surface was developed to facilitate remote tissue palpation and tumour localization. The objective of this research was to compare the performance of the minimally invasive robot-assisted TSI to human palpation for reliably locating hidden soft-tissue tumours.
Five-and 10-mm thermoplastic phantom tumours were randomly embedded in ex vivo bovine liver. The TSI was used to locate the tumours, guided by either a Mistubishi PA10–7C robot or a human. Eighteen specimens containing between 0 and 2 phantom tumours were palpated with each of the methods. Performance was assessed by measuring accuracy (the proportion of tests that were correctly identified as having or not having a tumour), exerted force and completion time. An ANOVA test was performed to establish differences among the different methods, followed by a Dunnett test to determine significant differences between the individual groups (see Table 1).
Table 1
Robotic assistance realized a 55% decrease in the maximum forces applied on tissue, a 50% decrease in task completion time and a 29% increase in tumour detection accuracy. These results imply that the use of robotic assistance for tactile sensing during MIS is not only feasible, but results in reduced tissue trauma and increased tumour detection, compared with manual manipulation with the tactile sensing instrument. Furthermore, robot-assisted palpation with a tactile sensing instrument has the potential to more accurately locate hidden tumours during MIS.
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JOINT VENTURE IN MINIMALLY INVASIVE THORACIC SURGERY. TACKLING THE LEARNING CURVE BY COMBINING THE EXPERTISE OF A THORACIC AND A LAPAROSCOPIC SURGEON. E. Joos, R. Labbé, J.P. Gagné. Québec Centre for Minimally Invasive Surgery, Centre hospitalier universitaire de Québec, Québec, Que.
The objective of this study was to evaluate the results of a thoracic surgeon with limited experience in minimally invasive surgery (MIS) undertaking, with the initial assistance of an MIS surgeon, resections of lung neoplasm by video-assisted thoracoscopic surgery (VATS).
Between May 2007 and February 2008, all candidates for a lobectomy for cancer were offered VATS, with the MIS surgeon assisting in the first 6 procedures. Charts were reviewed. Data included demographics, American Society of Anesthesiologists (ASA) classification, pulmonary functions tests, types of resections, staging, histology and perioperative outcome.
There were 19 patients with a mean age of 63.8 (45–76) years. ASA classification was I (0%), II (79%), III (21%). Mean forced vital capacity (FVC) and mean FEV1 were 3.11 L and 2.09 L, respectively. Resections were right upper lobe 8, right middle lobe 1, right lower lobe 2, left upper lobe 5 and left lower lobe 3. Surgical stages were Ia (9), Ib (4), IIa (1) and IIb (1). Other diagnoses included metastases (3) and granuloma (1). Mean tumour size and mean number of lymph nodes were 2.69 (1–7) cm and 4.4 (1–9), respectively. Most lesions were adenocarcinomas (15). Five patients had postoperative complications. Median operative time was 148 (53–226) minutes, 120 for the first 6 cases and 150 for the last 13. There were 2 conversions (10.5%), no transfusions and no mortality. Median length of stay was 6 (3–49) days.
VATS can be undertaken safely by a thoracic surgeon with minimal expertise in MIS. Combining the expertise of such a surgeon and a fellowship-trained laparoscopic surgeon might be the best way to accomplish the transition from open to minimally invasive thoracic surgery.
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RETROSPECTIVE ANALYSIS OF SURGICAL THORACIC OUTLET SYNDROME CASES. B. Nelems, M.F. Humer, W. Senner. Department of British Columbia Thoracic Surgery, Interior Health Authority, Kelowna General Hospital, Kelowna, BC.
The objective of this study is to assess surgical outcomes for thoracic outlet syndrome patients. A 10-year retrospective study which included chart reviews of 394 procedures was carried out using a predesigned data collection worksheet. Three surgical approaches were critically analyzed: transaxillary first rib resection, cervical rib resection and cervical sympathectomy when performed concurrently with rib resection. The results indicate that surgical intervention is beneficial, with improved symptomolgy, increased functional capacity and significant improvement in pain management. In conclusion, with proper assessment, diagnostic testing and consultation before surgical intervention outcomes for thoracic outlet syndrome, patients can be improved.
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FUNCTIONAL AND SYMPTOMATIC ASSESSMENT FOLLOWING LAPAROSCOPIC HELLER MYOTOMY AND PARTIAL FUNDOPLICATION FOR ACHALASIA — A 3-YEAR EXPERIENCE. A. Abdurahman, G.P. Giraldo, R.S. Sundaresan, D.E. Maziak, F.M. Shamji, A.J.E. Seely. Division of Thoracic Surgery, The Ottawa Hospital, Ottawa, Ont.
Laparoscopic surgery is an established method of treatment for achalasia, yet no data exist regarding outcomes and surgeon experience. The aim of this retrospective study was to assess functional and subjective outcomes following laparoscopic Heller myotomy and partial fundoplication for achalasia over a 3-year initial experience.
Data were collected from consecutive patients undergoing laparoscopic treatment of achalasia after initiation of a program of minimally invasive surgery (MIS) of the gastresophageal junction (GEJ) at a single thoracic surgical centre. Functional assessment (manometry) and symptom severity scores (questionnaires) were obtained pre-and postoperatively. Twenty-seven patients underwent laparoscopic modified Heller myotomy and partial (Dor) fundoplication from July 2004 to July 2007; 7 were performed in year 1 and 10 in both year 2 and 3. Length of stay (LOS) was a median of 2.0 and mean of 2.6 days. Perioperative complications occurred in 2 patients (7%) and included 1 conversion to open (bleeding) and 1 esophageal leak (radiologically diagnosed) which resolved without need for intervention. Preoperative manometry was performed in all patients; 11 (41%) agreed to undergo postoperative manometry and 14 (52%) completed pre-and postoperative symptom severity questions (LES). Average tone decreased from 44.5 ± 15.7 to 21.1 ± 5.5 mm Hg; percent relaxation increased from 43% ± 13% to 71% ± 13%; LES residual pressure decreased from 19.8 ± 8.8 to 6.2 ± 2.5 mm Hg, all p < 0.001; no difference was noted in LES length: 3.8 (SD 0.5) pre-and 3.4 (SD 0.6) cm postoperative, NS. Following surgery, symptom scores for dysphagia, gastroesophageal reflux symptoms and odynophagia were all significantly improved (p < 0.01). There were no differences in LOS or postoperative manometry and/or symptom scores in patients performed in years 1, 2 and 3.
Laparoscopic Heller myotomy and partial fundoplication improve LES function and symptoms in patients with achalasia. We detected no change in LOS, postoperative LES function or symptoms within the first 3 years of introducing a program of MIS GEJ surgery.
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THE EFFECT OF LAPAROSCOPIC PARAESOPHAGEAL HERNIA REPAIR ON PULMONARY FUNCTION TEST. S. Alnassar, J. Kondra, J. Clifton, R.J. Finley. Division of Thoracic Surgery, University of British Columbia, Vancouver, BC.
A retrospective cohort study was conducted to examine the impact of laparoscopic paraesophageal hernia repair on pulmonary function (PFT) and quality of life (QOL).
Between 2001 to 2005, 43 patients were diagnosed with paraesophageal hernia. Patients were evaluated by history, physical examination, chest radiograph (CXR), barium swallow and upper endoscopy. PFT was done preoperatively within 3 months before surgery and postoperatively at least 1 month after surgery. Postoperative QOL was evaluated using the Gastrointestinal Quality of Life Index (GIQLI), Chronic Respiratory Questionnaire (CRQ) and Likert symptoms scale.
Thirty-eight patients (10 male, 28 female) were included in the study: mean age was 71 (standard deviation [SD] 11.4, range 36–87) years. Presenting symptoms included gastroesophageal reflux (47.0%), dysphagia (34.2%), anemia (18.0%), dyspnea (32.4%), chest pain (60%) and cough (5%). Six patients had type II hernia, 26 type III and 6 type IV. Mean ASA was 2.5 (SD 0.65). Mean FEV1 (10.0%; preoperatively 2.17 [SD 0.78] L, postoperatively 2.38 [SD 0.92] L, p = 0.002); forced vital capacity (9.3%; preoperatively 3.01 [SD 1.05] L, posteratively 3.27 [SD 1.22] L, p = 0.001) and total lung capacity (8.3%; preoperatively 5.95 [SD 1.59] L, postoperatively 6.43 [SD 1.49] L, p = 0.002) improved significantly. Improvements were also seen in FEV1/FVC% (2.0%; preoperatively 71.57% [SD 8.5%], postoperatively 72.87% [SD 9.04%], p = 0.166) and residual volume (7.8%; preoperatively 2.34 [SD 0.68] L, postoperatively 2.51 [SD 0.45] L, p = 0.123), but they were not statistically significant. Improved symptom scores were shortness of breath 3.73 (SD 1.03), chest pain 4.43 (SD 1.0), heartburn 4.33 (SD 1.11), regurgitation 4.57 (SD 0.94) and dysphagia 4.1 (SD 1.1). Mean GIQLI (out of 100) was 70.95 (SD 12.73, range 49–90); mean CRQ was 3.56 (SD 1.2, range 2.2–5.8) for the dyspnea domain, 5.35 (SD 0.88, range 3.86–7.0) for the emotional domain, 5.50 (SD 1.37, range 3.25–7.00) for the mastery domain and 4.13 (SD 0.85, range 2.25–5.50) for the fatigue domain. Mean length of stay 2.6 (SD 1.9) days. Minor postoperative complications occurred in 5 patients (14.7%). No in-hospital or 30-day mortality occurred.
Laparoscopic repair of paraesophageal hernia results in a significant improvement of PFT and is well tolerated by elderly patients with other comorbid diseases. It improves symptoms of shortness of breath, chest pain, heartburn, regurgitation, dysphagia and improves quality of life.