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Background: The study aim is to compare the diagnostic yield, safety, and cost of outpatient awake thoracoscopy (AT) with video-assisted thoracoscopic surgery (VATS) pleural biopsy in undiagnosed pleural effusions., Methods: The diagnostic yield of pleural biopsy performed by AT or VATS in patients with undiagnosed exudative pleural effusions at a tertiary thoracic surgery center in Canada between 2011 and 2015 was retrospectively evaluated. Test sensitivity, specificity, positive predictive value, and negative predictive value were compared. Procedure safety, hospital length of stay, additional pleural-based interventions, and procedure-related costs were compared., Results: Patients underwent either AT (n = 78) or VATS (n = 99) during the study period. Sensitivity, specificity, positive predictive value, and negative predictive value were 85%, 100%, 100%, and 79% for AT and 93%, 94%, 99%, and 76% for VATS, with no significant difference in diagnostic test performance. There was no difference in the rate of major complications (2 AT [2.6%] versus 4 VATS [4.0%], p = 0.696), minor complications (14 AT [17.9%] versus 16 VATS [16.2%], p = 0.841) or need for additional pleural-based procedures (20 AT [25.6%] versus 18 VATS [18.2%], p = 0.270). The VATS was associated with longer median hospital stay (VATS 3 days [interquartile range: 1 to 4] versus AT 0 days [interquartile range: 0 to 1], z = 6.98, p < 0.001) and a higher procedure-related average cost (VATS Canadian dollars $7,962 [95% confidence interval: $7,134 to $8,790] versus AT Canadian dollars $2,815 [95% confidence interval: $2,010 to $3,620], p < 0.001)., Conclusions: Awake thoracoscopy and VATS have similar diagnostic yield and safety profiles in the assessment of undiagnosed pleural effusions; however, AT is associated with shorter length of stay and lower average per-procedure cost. In the appropriate clinical setting, AT may be the diagnostic test of choice., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Robotic surgery was introduced as a platform for minimally invasive lung resection in Canada in October 2011. We present the first Canadian series of robotic pulmonary resection for lung cancer., Methods: Prospective databases at 2 institutions were queried for patients who underwent robotic resection for lung cancer between October 2011 and June 2015. To examine the effect of learning curves on patient and process outcomes, data were organized into 3 temporal tertiles, stratified by surgeon., Results: A total of 167 consecutive patients were included in the study. Median age was 66 (range 27-88) years, and 46.1% ( n = 77) of patients were men. The majority of patients ( n = 141, 84%) underwent robotic lobectomy. Median duration of surgery was 270 (interquartile range [IQR] 233-326) minutes, and median length of stay (LOS) was 4 (IQR 3-6) days. Twelve patients (7%) were converted to thoracotomy. Total duration of surgery and console time decreased significantly ( p < 0.001) across tertiles, with a steady decline until case 20, followed by a plateau effect. Across tertiles, there was no significant difference in LOS, number of lymph node stations removed, or perioperative complications., Conclusion: The results of this case series are comparable to those reported in the literature. A prospective study to examine the outcomes and cost of robotic pulmonary resection compared with video-assisted thoracoscopic surgery should be done in the context of the Canadian health care system. We have presented the first consecutive case series of robotic lobectomy in Canada. Outcomes compare favourably to other series in the literature.

Donor-specific HLA antibodies (DSA) have an adverse effect on short-term and long-term lung transplant outcomes. We implemented a perioperative strategy to treat DSA-positive recipients, leading to equivalent rejection and graft survival outcomes. Pretransplant DSA were identified to HLA-A, B, C, DR and DQ antigens. DSA-positive patients were transplanted if panel reactive antibody (PRA) ≥30% or medically urgent and desensitized with perioperative plasma exchange, intravenous immune globulin, antithymocyte globulin (ATG), and mycophenolic acid (MPA). PRA-positive/DSA-negative recipients received MPA. Unsensitized patients received routine cyclosporine, azathioprine and prednisone without ATG. From 2008-2011, 340 lung-only first transplants were performed: 53 DSA-positive, 93 PRA-positive/DSA-negative and 194 unsensitized. Thirty-day survival was 96 %/99%/96% in the three groups, respectively. One-year graft survival was 89%/88%/86% (p = 0.47). DSA-positive and PRA-positive/DSA-negative patients were less likely to experience any ≥ grade 2 acute rejection (9% and 9% vs. 18% unsensitized p = 0.04). Maximum predicted forced expiratory volume (1 s) (81%/74%/76%, p = NS) and predicted forced vital capacity (81%/77%/78%, respectively, p = NS) were equivalent between groups. With the application of this perioperative treatment protocol, lung transplantation can be safely performed in DSA/PRA-positive patients, with similar outcomes to unsensitized recipients., (© Copyright 2015 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Objective: To provide guidelines for antimicrobial prophylaxis on the basis of the type of surgical procedure., Options: Standard drug regimens for prophylaxis of infection in a variety of surgical procedures were considered, including a first-generation cephalosporin; an aminoglycoside in combination with metronidazole, clindamycin or erythromycin; a second-generation cephalosporin; and trimethoprim-sulfamethoxazole., Outcomes: In order of importance: efficacy, side effects and cost., Evidence: A MEDLINE search of articles published between January 1980 and December 1991. For clinical trial data, greatest emphasis was placed on randomized, double-blind studies using appropriate controls., Values: The Committee on Antimicrobial Agents of the Canadian Infectious Disease Society (CIDS) and two recognized experts (T.K.W. and O.D.R.) recommended antimicrobial regimens suitable for prophylaxis of infections in surgery. Whenever possible, recommendations were based on data from randomized controlled trials., Benefits, Harms and Costs: Implementation of the guidelines is expected to reduce the incidence of postoperative infections, the inappropriate use of antibiotics and costs to hospitals., Recommendations: Antibiotic prophylaxis is recommended for operations with a high risk of postoperative wound infection or with a low risk of infection but significant consequences if infection occurs. These operations include clean-contaminated procedures and certain clean procedures. Drugs should be administered intravenously immediately before the operation. In colorectal operations oral administration also appears to be effective. A single dose is sufficient for most procedures. The regimen chosen depends on the pathogens usually associated with wound infection in a given operation, the serum half-life of the drugs, the antimicrobial susceptibility patterns in the local hospital and the cost of the drugs., Validation: The guidelines were compared with others in standard textbooks of surgery and peer-reviewed articles. The guidelines were prepared and revised by the Committee on Antimicrobial Agents of the CIDS. They were then reviewed and revised further by the Council of the CIDS., Sponsor: The CIDS was solely responsible for developing, funding and endorsing these guidelines.

The minimum number of seriously injured patients required to maintain clinical competence and achieve acceptable clinical competence in a single trauma centre is unknown. It has been suggested that the probability of survival is improved in hospitals treating greater than 200 trauma patients annually. We sought to determine if probability of survival was lower in our small volume centre. Between 1986 and 1989, 752 (522 male, 230 female; average age, 36 years) trauma patients were admitted to our institution. The major mechanism of injury was blunt (89%). All patients underwent trauma severity scoring. Trauma Score, Injury Severity Score, and a Revised Trauma Score were used to derived the probability of survival by the TRISS method. The mean Injury Severity Score was 23.3 and the mean Trauma Score was 13.2. The overall mortality rate was 15.8%. The Z statistic demonstrated no significant difference between actual and predicted deaths for the 4-year period or for any individual year (range, -1.05 to 1.26, p greater than 0.05). The M statistic was 0.753. We conclude that, despite fewer trauma patient admissions (less than 200 per year), comparable clinical results can be achieved by surgeons dedicated to trauma management.