Surgeons' day 2004

Twenty-Second Annual Department of Surgery SURGEONS' DAY 2004
I would like to welcome you all to the 22nd Annual Department of SurgeryResearch Symposium. This event serves to highlight the research activities ofthe department. This year it has continued to expand in scope, showcasing aneven larger number of resident research proposals, as well as a record numberof fellowship poster presentations and presentations from medical students. The ever increasing quality and quantity of the research activity done withinthe department is a direct reflection of the academic vision within thedepartment. As in the past, the podium presentations of Surgeons' Day areprimarily to allow residents to showcase the results of their research efforts.
To accommodate the increasing number of post residency and fellowshippositions we have also continued to encourage presentations at our postersession. This also allows a venue for faculty and other professionals associatedwith our department to display their research for the year.
Fundamentally, Surgeons' Day acts as a communication forum for thedepartment. The discussion of the research is an important starting point.
However, equally as important, is the opportunity to renew acquaintances,discuss cases and problems, and exchange ideas across divisions and locations.
The Friday evening dinner continues to be a very enjoyable social event, andalso allows us to appropriately honour more senior members of the department. Surgeons' Day also allows us to learn from our guests; this year we have anexceptional combination. Dr. Maddern is a General Surgeon from Australia;he has a world-wide reputation in evaluating outcomes of new surgicaltechnologies. Dr. Paul Kubes, from within our own faculty, has a world-wide reputation inunderstanding the basic mechanisms behind recruitment of cells into inflamedtissues. We look forward to the input of the judges, both in their review of theResidents' projects, as well the presentation of their own material.
Surgeons' Day also allows us to interact with our corporate sponsors. Weappreciate very much the sponsorship from the commercial sector, which bothenhances the event, allows for ongoing exchange about new technologies, andallows us to continue to improve the care of our patients.
And so, as the events of Surgeons' Day unfold sit back, relax and enjoy whatpromises to be a banner year of research material. I hope you enjoy the 2004program. Congratulations to all the presenters for their hard work and theirexcellent results.
David L. Sigalet, MD, PhD, FRCSC, FACS Surgeons' Day is an annual event in the Calgary Regional Clinical Department ofSurgery. It was established in 1983 and the goal of Surgeons' Day was, and is, tohighlight the research activities of residents in the department. Each year an awardhas been given to the resident presenting the best paper. In 1989, Dr. Watanabe,Dean of the Faculty of Medicine, instituted the Ruth Rannie Award, a $1,000 prizefor the best overall paper. In recognition of the excellent basic and clinical researchbeing done by our residents, we elected to give two awards in 2000. This year, theRuth Rannie Award has been allocated to another endeavor and in its place we will beawarding the John Smith and Laura May Gardner Memorial Endowment. Thisendowment was specifically set up to issue awards within the Department of Surgery.
Winners of the Ruth Rannie Award
Beginning in 2001, due to the outstanding clinical and basic research presented in thepast, the Department elected to give two awards to highlight each area of research.
Dr. Darlene Fenech – Clinical Research Award – "Transanal Excision ofRectal Polyps and Cancers" Dr. John Hwang – Basic Research Award – "Mechanisms of LeukocyteRecruitment in Oxazolone-Induced Murine Contact Hypersensitivity" Dr. Sandy Widder – Clinical Research Award – "Prospective Evaluation ofCT Scanning for the Spinal Clearance of Unconscious Trauma Patients" Dr. Paul Beaudry – Basic Research Award – "Correlation of Sodium-IodideSymporter Expression with Prognostic Factors in Papillary Thyroid Cancer" Dr. Eli Olschewski – Clinical Research Award – "Lumbar ParavertebralNerve Block in the Management of Pain, Following Total Hip and KneeArthroplasty: A Randomized Controlled Clinical Trial" Dr. Jeannie Sham – Basic Research Award – "Epidermal Growth FactorImproves Outcome in a Rat Model of Short Bowel Syndrome" The Ruth Rannie Award was presented to two individuals: Dr. May Lynn Quan – "Sentinel Node Biopsy in Breast Cancer: Is AccuracyImproved by Removing More Than One Node?" Dr. Jason Howard – "Biomechanical Analysis of Cemented Versus Non-Cemented Initial Fixation of the Tibial Stem in Total Knee Arthroplasty:Quantification of Implant Migration" Scott Timmermann – "Healing Responses of the ACL and MCL: Comparisonin an Experimental Sheep Model" Dr. Geoff Ibbotson – "Increased Leukocyte Recruitment Response in SepticICU Patients" The Ruth Rannie Award was presented to two individuals: Dr. Scott Timmermann – "Gene Therapy in Ligament Healing: Optimizationof Cellular Transfection" Dr. Bob Kiaii – "The Basis of Impaired Gallbladder Contractility byProgesterone In Vitro" Dr. Eric Torstensen – "Comparison of MRI and Arthroscopy in theEvaluation of Shoulder Pathology" Dr. Deiderick Jalink – "Hyperdynamic Circulation of a Rat Biliary Cirrhosisis Reversed by Bilioenteric Anastomosis" Dr. Greig McAvoy – "Walking Efficiency with Osteoarthritis of the Hip" Dr. Kevin Hildebrand – "Validation of a Visual Analogue Scale for CalcanealFractures" Dr. Daphne Mew – "In Vitro Activation of Melanoma Specific Cytotoxic T-Lymphocytes Using Synthetic Antigens GM2/GD3" Dr. Phil Mitchell – "Cooperative Hernia Study: Recruitment, Exclusions, andPreliminary Follow-up" 1990 Dr. Leon Pontikes – "The Effect of Mechanical Bowel Preparation on Wound Infection Rates in Operations Involving the Left Side of the Colon" Dr. Daphne Mew – "Tumor Localization with a Monoclonal Antibody" Dr. Peter Cruse Awards
In 1996, the Dr. Peter Cruse Award was established to honor the outstandingcontributions of Dr. Cruse to medical education. The Cruse Award is given to amedical student with the best surgery-related research project. Dr. John Grant, Medical Student, University of Calgary – Winner
"Two to Four Year Follow-up of a Comparison of Home vs. Physiotherapy-
Supervised Rehabilitation Programs Following ACL Reconstruction"
Ms. Vithya Gnanakumar, Medical Student, University of Calgary –
Honorable Mention "BIRADS Interpretation by Family Doctors and
Mammography Patients in Directing Breast Biopsy, Surgical Intervention and
Patient Anxiety"
Academic Poster Session
In 2001, we also instituted an academic poster session. Members and investigatorsassociated with the Department of Surgery, including Surgeons, Residents, Fellows,and Medical Students present their research, in poster format, on the eve of theSurgeons' Day Symposium. This event was very well received by the presenters andby those attending the poster sessions. The poster session is being held as an annualevent. We now have a continuum from medical student, to resident, to post-doctoraland clinical fellows, as well as surgeons in our Surgeons' Day Research Symposium.
Distinguished Guest Adjudicators
In keeping with tradition, we are proud to have two outstanding academic scientists asour guest adjudicators: Dr. Paul Kubes – the McMurtry Lecturer, and Professor GuyMaddern – the McPhedran Lecturer.
Dr. Paul Kubes - McMurtry Lecturer
Dr. Kubes did his graduate work at Queen's University in Kingston Ontario. Hestudied the mechanisms of blood flow redistribution to vital organs during a crisissuch as a hemorrhage or during hypoxia. This was done under the guidance of Dr.
Chris Chapler. He continued to study cardiovascular physiology and pathophysiologyas an MRC postdoctoral fellow with Dr. Neil Granger at Louisiana State UniversityMedical School. He studied ischemia/reperfusion and what was the major source offree radicals in postischemic tissues. They developed a technique termed intravitalmicroscopy which allows for the visualization of postcapillary venules and theyobserved a huge infiltration of neutrophils at the time of reperfusion. In 1991, he moved back to Canada to start his own laboratory because of anopportunity provided by the Alberta Heritage Foundation for Medical Research. Heentered the field of adhesion molecules and have trying to understand how variousleukocytes infiltrate different tissues under acute, chronic and systemic inflammation.
In the process he uncovered that nitric oxide is a major "Teflon" for blood vesselskeeping neutrophils from adhering and he demonstrated that inhaled nitric oxidecould reach the periphery to affect neutrophil recruitment. Finally, they haveidentified that under certain situations novel adhesion molecules can be expressed onneutrophils explaining some of the difficulty in inhibiting neutrophil recruitment incertain inflammatory conditions. His work is presently sponsored, primarily, by theCanadian Institutes of Health, as well as the Heart and Stroke Foundation of Canada,the Crohn's Colitis Foundation and Bayer. He holds a Canada Research Chair.
Professor Guy Maddern - McPhedran Lecturer
Professor Guy Maddern is the RP Jepson Professor of Surgery at the University ofAdelaide and Director of Surgery at The Queen Elizabeth Hospital. He was trainedat the University of Adelaide and became a Fellow of the Royal Australasian Collegeof Surgeons in 1989. His clinical interests include the physiological impact oflaparoscopic surgery, and more recently the development of techniques to managemetastatic hepatic disease. He has over 200 publications in scientific journals andhas contributed to over a dozen surgical publications.
At the commencement of 1996 Professor Maddern was appointed Director of theClinical Development Research Centre, now the Basil Hetzel Institute, at The QueenElizabeth Hospital charged with the responsibility of defining the future direction anddevelopment of research within The Queen Elizabeth Hospital campus.
In November 1997 he was appointed Surgical Director of the Australian Safety andEfficacy Register of New Interventional Procedures – Surgical (ASERNIP-S). Thisorganization, funded by the Federal Government through the Royal AustralasianCollege of Surgeons, is a programme designed to perform rigorous assessments on thesafety and efficacy of new procedures and technologies available in surgical practice,and feed back this information to surgeons and the community.
Professor Maddern has received in excess of $11,500,000 in research fundingincluding $5,700,000 from the Commonwealth Department of Health and Aging and$720,000 from the National Health and Medical Research Council. He sits onnumerous committees and is Vice-President of the Australian Patient SafetyFoundation and a Federal Councillor of the Royal Australasian College of Surgeons.
Welcome to Surgeons' Day 2004, we are proud of this year's event and we hope youenjoy it also.
CORPORATE SPONSORS FOR SURGEONS' DAY 2004
We wish to thank the following corporations for supporting the 2004Surgeons' Day Symposium.
AMT Electrosurgery
Cook Canada
KCI Medical Canada
Ethicon
Canada Diagnostic Centres
Baxter Corporation
Optimed Software Corporation
TABLE OF CONTENTS
THE SPECTRUM OF SURGICAL INTERVENTIONS IN CHILDREN WITH
CEREBRAL PALSY: A POPULATION BASED STUDY……………………10
Dr. Scott Gmora, Division of General Surgery, R2 A CRITICAL TEMPORAL WINDOW FOR SELECTIN-DEPENDENT CD4+
LYMPHOCYTE HOMING AND INITIATION OF LATE PHASE
INFLAMMATION IN CONTACT SENSITIVITY…………………………….11
Dr. John Hwang, Division of General Surgery, Surgeon Scientist Program ENDOSCOPIC LASER SPECKLE PERFUSION IMAGING IN THE HUMAN
KNEE …………………………………………………………………………….12
Dr. Jeremy Reed, Division of Orthopaedic Surgery, R3 QUALITY OF LIFE AFTER EXCISION OF RECTAL CANCER………….13
Dr. Shawn MacKenzie, Division of General Surgery, R3 TORADOL AND MARCAINE FOR THE CONTROL OF POSTOPERATIVE
PAIN IN BREAST AUGMENTATION PATIENTS: TEN DAYS OF
FOLLOW-UP………………………………………………………………….…14
Dr. Raman Mahabir, Division of Plastic Surgery, R3 COMPARISON OF DATA EXTRACTION FROM STANDARIZED VERSUS
TRADITIONAL OPERATIVE REPORTS FOR DATABASE RELATED
RESEARCH AND QUALITY CONTROL…………………………………….15
Dr. Adrian Harvey, Division of General Surgery, R3 CEREBRAL FAT EMBOLISM FOLLOWING FEMUR FRACTURE…….16
Dr. Ayesha Abdeen, Division of Orthopaedic Surgery, R4 MANAGEMENT OF PEDIATRIC SPLENIC TRAUMA: A 10-YEAR
CALGARIAN EXPERIENCE………………………………………………….17
Dr. Sandy Widder, Division of General Surgery, R3 THE EFFECTS OF PERIARTICULAR MUSCLE WEAKNESS IN THE
EXERCISED RABBIT KNEE………………………………………………….18
Dr. David Longino, Division of Orthopaedic Surgery, R3 GLUCAGON-LIKE PEPTIDE-2 INDUCES INTESTINAL ADAPTATION IN
PARENTERALLY FED RATS WITH MASSIVE DISTAL SMALL BOWEL
RESECTION…………………………………………………………………….19
Dr. Osama Bawazir, Division of Pediatric Surgery, R7 RECONSTRUCTION FOLLOWING MASTECTOMY FOR STAGE I/II
BREAST CANCER: A POPULATION BASED STUDY………………………20
Dr. Jayson Dool, Division of Plastic Surgery, R4 THORACIC PARAVERTEBRAL BLOCK IN BREAST SURGERY……….21
Dr. Jennifer Hankins, Division of General Surgery, R5 EPIDEMIOLOGY OF SEVERE TRAUMA IN STATUS ABORIGINAL
CANADIANS: A POPULATION BASED STUDY…………………………….22
Dr. Shazeer Karmali, Division of General Surgery, R2 THE BUFORD COMPLEX: INCONSEQUENTIAL VARIANT OR
PREDISPOSITION TO SLAP LESION……………………………………….23
Dr. Paul Dooley, Division of Orthopaedic Surgery, R3 THE SPECTRUM OF ADRENAL LESIONS ASSESSED IN THE ERA OF
ADRENAL INCIDENTALOMAS………………………………………………24
Dr. Juan Chavez-Rodrigues, Fellow, Endocrine Surgery TWO TO FOUR YEAR FOLLOW-UP OF A COMPARISON OF HOME VS.
PHYSIOTHERAPY-SUPERVISED REHABILITATION PROGRAMS
FOLLOWING ACL RECONSTRUCTION……………………………………25
Dr. John Grant, Medical Student (Dr. Peter Cruse Award – 1st Place) BIRADS INTERPRETATION BY FAMILY DOCTORS AND
MAMMOGRAPHY PATIENTS IN DIRECTING BREAST BIOPSY,
SURGICAL INTERVENTION AND PATIENT ANXIETY…………………26
Ms. Vithya Gnanakumar, Medical Student (Dr. Peter Cruse Award –Honorable Mention) Dr. G. Swamy, Fellow, Spine Surgery A MODIFIED EILBER PROTOCOL PROVIDES MAXIMUM LOCAL
CONTROL AND MINIMUM MAJOR MORBIDITY IN SOFT TISSUE
Dr. Lloyd Mack, Fellow, Surgical Oncology VERTEBRAL ARTERY ECTASIA AND POSTERIOR C1-C2
TRANSARTICULAR SCREW FIXATION—REAL OR PERCEIVED
Dr. J.F. Chevalier, Fellow, Spine Surgery THE SPECTRUM OF SURGICAL INTERVENTIONS IN CHILDREN WITH
A POPULATION-BASED STUDY
Scott Gmora
Division of General Surgery, R2
Co-Investigators(s): Dr. D. Poenaru & Dr. G. Smith
Objective: To describe the spectrum of surgical procedures undergone by a population of
children with cerebral palsy (CP), and to determine the manner in which these surgical
procedures vary according to the clinical subtype of CP.
Methods: We retrospectively reviewed the medical records of all children with CP (N=103)
born between 1984 and 2001 and followed at a provincially designated treatment centre in
Kingston, Ontario. Information regarding the nature of the participants' disability and the
surgical interventions that each child underwent was gathered. Participants were categorized
based on their disability into: spastic quadriplegia, spastic diplegia, spastic hemiplegia, and
other. Information regarding the type, timing, and indications for all surgical procedures across
all surgical subspecialties were recorded.
Results: Approximately 75% of children included in this study underwent at least 1 surgical
intervention[0]. Orthopedic surgery accounted for the great majority of surgical interventions
with 56.3% of children requiring at least one orthopedic surgery. The majority of these
procedures involved the treatment of hip instability and static contracture/dynamic muscle
imbalances. Follow-up contrasts revealed a statistically significant difference in the number of
surgeries across each of the spastic types (quadriplegia> diplegia> hemiplegia) (p<.05 for
each). General surgery was the next most common surgery with 18.4% of children requiring at
least one such procedure. The most frequent procedures were percutaneous endoscopic
gastrostomies (PEG) (43.8%) and Nissen fundoplications (28.1[0]%). In contrast to
orthopaedic interventions, general surgery procedures were skewed to the most severe forms of
CP with the preponderance of surgeries being confined to children with spastic quadriplegia.
Surgical interventions is the remaining subspecialties were, comparatively, far less frequent.
Conclusions: Surgical interventions are frequent in children with cerebral palsy. The majority
of interventions are orthopedic and gastrointestinal in nature. The incidence and nature of
interventions vary dramatically across the various CP subtypes.
A Critical Temporal Window for Selectin-Dependent CD4+ Lymphocyte
Homing and Initiation of Late Phase Inflammation in Contact Sensitivity
John M. Hwang
Division of General Surgery, R3
Co-Investigators: Jun Yamanouchi, Pere Santamaria and Paul Kubes
Contact sensitivity (CS) is an inflammatory disorder characterized by early andlate phases of leukocyte recruitment. To fully elaborate events at theendothelial-leukocyte interface, we used a non-invasive intravital microscopytechnique that allows for the direct visualization of leukocyte rolling andadhesion on blood vessel endothelium. Using blocking antibodies againstspecific adhesion molecules, we elucidated the molecular mechanismsmediating early leukocyte recruitment (mainly neutrophils and lymphocytes) tobe E- and P-selectin and then demonstrated that leukocyte recruitment in thelate phase (primarily lymphocytes) had a different adhesive profile (mainly á4- integrin). Complete blockade of E- and P-selectin within the first 2 hours ofleukocyte-endothelial cell interactions (but not after this point) eliminated theselectin-independent leukocyte recruitment at 24 hours. Specific eliminationof CD4+ lymphocytes in the early phase eliminated the late phase response.
Fluorescently labeled CD4+ lymphocytes homed to skin via E- and P-selectinwithin the early phase and induced the late phase response. Interestingly,addition of these same CD4+ lymphocytes two hours after antigen challengewas too late for these cells to home to the skin and induce late phase responses.
Our data clearly demonstrate that the antigen challenged microenvironment isonly accessible to CD4+ lymphocytes for the first 2 hours and this process isabsolutely essential for the subsequent recruitment of other leukocytepopulations in late phase responses.
Endoscopic Laser Speckle Perfusion Imaging
in the Human Knee
Jeremy Reed
Division of Orthopaedic Surgery, R3
Co-Investigators: K. Forrester, C. Leonard, J. Tulip, R. Bray
Objective: To assess the endoscopic Laser Speckle Perfusion Imaging system's (eLSPI, a
novel device capable of real-time, optical, non-invasive measurement of tissueperfusion) ability to detect changes in tissue perfusion in the human kneesecondary to: 1. 2 consecutive episodes of tourniquet induced occlusion of blood flow.
2. Re-perfusion hyperemia following tourniquet release.
3. Epinephrine induced vasoconstriction at concentrations of 0.5x10-6M,1x10-6M, and 2x10-6M.
A series of 5 patients providing the first human data on a novel scientifictechnology.
Clinical data was attained in the Peter Lougheed Center operating suites betweenDecember of 2003 and February of 2004.
Subjects: 5 patients between the age of 18 and 42, 3 male and 2 female, requiring
arthroscopic knee surgery and consenting to involvement in the study.
Outcome Assessment of the eLSPI's ability to detect changes in perfusion resultant from
Measures: like interventions, both within and between patients.
In each patient, two sequential tourniquet inflations produced consistent decreases(mean difference from 1st to 2nd inflation = 3.06%, p = 0.67) in perfusion indexmeasurements (numerical values linearly related to blood flow). All patientsdemonstrated varying degrees of post-tourniquet hyperemia. The rate at which thehyperemia developed was uniform across patients (mean rate = .114u/sec). TheeLSPI was able to detect a dose dependent response to the administration of intra-articular epinephrine. These decreases in perfusion were not consistent acrosspatients.
Conclusions: The eLSPI system consistently detects changes in perfusion resultant from
tourniquet inflation, as well as a common rate of hyperemia post tourniquetrelease. The eLSPI is clearly able to detect decreases in perfusion resultant fromthe administration of increasing concentrations of epinephrine; however there isnot a significant correlation in the degree of epinephrine response across patients.
QUALITY OF LIFE AFTER EXCISION OF RECTAL CANCER
Division of General Surgery, R3
Co-investigator(s): Dr. T. MacLean, Dr. D. Buie, & Dr. J. Heine
Objective:
To determine if preoperative or postoperative chemotherapy and radiationtreatment affect quality of life and bowel function in patients receivingradical curative surgery for rectal adenocarcinoma.
Prospective cohort quality of life study comparing 3 treatment groups; 1)patients receiving neo-adjuvant chemo-radiation therapy, 2) patientsreceiving postoperative chemo-radiation therapy, and 3) patients notreceiving any adjuvant therapy.
Setting: Foothills Medical Centre and Peter Lougheed Hospital.
Subjects: Adult patients, undergoing curative radical anterior resection for adenocarcinoma
of the rectum, collected prospectively in a surgical database over an 8-yearperiod.
Interventions: Demographics, clinical circumstances, anal function, and quality of life
information will be collected from a databank review and mail-outquestionnaire. The European Organization for Research and Treatment of Cancer (EORTC)quality of life measurement tool specifically designed for colorectal cancerwill be utilized for postoperative measurement of function and Quality ofLife. Fecal incontinence will be assessed with a Fecal Incontinence ScoringSystem (FISS).
The EORTC Quality of life tool and FISS will be statistically analyzed todetermine if a difference exists between treatment groups.
Results & Conclusions:
Questionnaires have been sent to 185 rectal cancer patients, and pilot data isexpected at time of presentation.
Toradol and Marcaine for the control of postoperative pain in
breast augmentation patients: ten days of follow-up
Raman C. Mahabir
Division of Plastic Surgery, R3
Co-Investigators: BD Peterson, JS Williamson, SM Valnicek, DG Williamson, B East
Objective: Previously, it was shown that locally applied intraoperative Toradol and Marcaine
significantly reduced pain in the immediate postoperative period. The objective of this study
was to test the effectiveness of Toradol and Marcaine to reduce pain over the first ten days of
the postoperative period.
Design: Prospective, randomized, double-blind clinical trial with ethical approval. One
hundred consecutive breast augmentation patients were enrolled and informed consent was
obtained. A standard anaesthetic protocol and surgical procedure were followed.
Setting: Private Surgical Center.
Subjects: Adult females.
Interventions: Either normal saline, Ketorolac alone, Bupivicaine alone or Ketorolac and
Bupivicaine were irrigated into the implant pocket prior to insertion of the implant. All
patients completed the study. The power of this study to detect a 20% difference with respect
to the primary outcome was 0.90 and confidence intervals of 95% were used to determine
significance.
Outcome Measures: The primary outcome was pain as measured by the Visual Analog Pain
Scale (VAPS) and recorded in a take-home diary. The secondary outcome was morphine
equivalents of analgesics used.
Results:
Conclusion: Locally applied, intraoperative Toradol and Marcaine with epinephrine
significantly reduced pain and analgesic requirements postoperatively in women undergoing
primary augmentation mammoplasty.
COMPARISON OF DATA EXTRACTION FROM STANDARDIZED VERSUS
TRADITIONAL OPERATIVE REPORTS FOR DATABASE RELATED RESEARCH
AND QUALITY CONTROL
Division of General Surgery, R3
Co-Investigator(s): Dr. C. Brown & Dr. J. Nixon
Objective: To compare standardized (SR) with traditional (TR) operative reports for
laparoscopic cholecystectomy with respect to extraction of data base related information.
Design: Two separate physicians extracted data from the two report types into a spreadsheet.
The two physicians to eliminate any training effect performed extraction from standardized &
traditional reports in opposite order.
Setting: Participating surgeons & residents for all laparoscopic cholecystectomy procedures
during October to December 2004 performed standardized dictations. Traditional reports
dictated in the three months prior to the study period were pulled for comparison.
Intervention: A standardized dictation consisting of a summary paragraph template at the end
of the traditional operative report was developed through a survey of regional databases, a
review of the literature & input from participating surgeons. Data was extracted into an excel
spreadsheet by two physicians.
Outcome Measures: Completeness of data extraction from the two types of reports was the
main outcome measure. Compliance with the standardized dictation, time requirements &
inter-observer reliability of data extraction were secondary outcome measures.
Statistical Analysis: An analysis at the initiation of the study revealed that a sample size of
100 of each report types was required to detect a difference of 10% with a power of >0.80.
Non-parametric statistical analysis was used to compare the completeness of data extraction
from the two types of reports. Statistical significance was set at p<0.05.
Results: Compliance with the standardized report was 63.4%. Completeness of data
extraction for identifying variables such as patient name, age, date of procedure & surgeon was
similar between the two types of reports. Categorical variables such as the procedure urgency
(93.2 SR vs. 63.7% TR), admission status (97.5% SR vs. 49.0% TR), peri-operative antibiotics
(95.0% SR vs. 14.7% TR) & DVT prophylaxis (97.5% SR vs. 13.7% TR) were more
completely reported on the standardized dictation (p<0.05). In addition some qualitative (GB
appearance 100% SR vs. 37.3% TR) & quantitative variables (# artery clips 99.2% SR vs.
72.5% TR) were more consistently found on the standardized reports (p<0.05)
Conclusions: Standardized operative reports result in more efficient and complete data
extraction when compared to traditional dictations.
Cerebral Fat Embolism following Femur Fracture
Orthopaedic Surgery PGY-4
Co-Investigators: C. Doig, J. Powell, M. Hameed, R. Sevick, G. Marshall
Objective: To determine whether there is evidence of clinically relevant cerebral edema
demonstrated on diffusion weighted 3T-MR images in trauma patients who have had
intramedullary femoral nailing following a femur fracture
Design: prospective cohort study
Setting: Level I trauma center, Foothills Hospital, Calgary, AB
Subjects: Subjects aged 18-50 sustaining a femur fracture requiring intramedullary nailing
Main Outcome Measures: The presence of cerebral ischemia /edema demonstrated by
diffusion weighted (DW) MRI as quantified by apparent diffusion coefficient (ADC).
Secondary outcome measures were neuropsychiatric testing including mini-mental status exam,
clock drawing test and symbol digits modalities test.
Results: Interim data of 4 subjects enrolled in the study revealed one patient with fat embolism
syndrome. This patient scored the following test results: MMSE 15; clock drawing 7; S.D 5.
The average results of the 3 remaining patients with negative MRI findings were respectively,
0.67, 25.3, 29.9.
Conclusions: Neuropsychiatric test scores correlated inversely to the amount of cerebral
edema as measured by diffusion weighted MRI suggesting that DW-MRI may be predictive of
the clinical manifestations of cerebral fat emboli. Evidence of cerebral fat embolism as per
DW MRI may be of diagnostic and prognostic value in the assessment of patients with
cerebral dysfunction following long bone fracture.
Management of Pediatric Splenic Trauma: A 10 Year Calgarian Experience
Sandy Widder
Division of General Surgery, R3
Co-Investigators: Drs. A. Wong, R. Eccles, D. Sigalet
Objective: 1. To review pediatric splenic trauma of 10 years experience at a major
Canadian tertiary centre.
2. To determine the incidence of pseudoaneurysms.
3. To determine whether or not pseudoaneurysms contribute to failure of conservative management.
Design: Retrospective chart review of 10 years experience (1993-2003) at a major
Canadian pediatric tertiary care centre.
Subjects: Inclusion criteria: Age less than 18
Splenic trauma (blunt or penetrating) Follow up imaging post-discharge Outcome Measures: Incidence of pseudoaneurysms.
Success rate of non-operative management in Calgary.
Factors which most likely lead to failure.
Statistical Analysis: Linear regression analysis
Results: 137 patients met the inclusion criteria. 104 were male. 33 were female. The
mean age was 10.8 years. 7 patients failed conservative management, 3 initially and 4 late. The incidence of pseudoaneurysms was 4. All pseudoaneurysms were detected via ultrasound, and were treated conservatively. Conclusions: Calgary has a 5.1% failure rate. Pseudoaneurysms of the splenic artery are a
rare entity, and do not lead to failure of non-operative management.
The Effects of Peri-articular Muscle Weakness in the Exercised Rabbit Knee
Division of Orthopedic Surgery, R3
Co-Investigators: C. Frank, W. Herzog
Objective: To investigate the influence of peri-articular muscle weakness on cartilage health in
an exercised stable joint.
Design: Experimental animal model.
Setting: Animal Resource Centre, University of Calgary.
Subjects: One-year-old, skeletally mature, New Zealand white rabbits.
Interventions: Group 1 (n=5) received unilateral botulinum toxin (BTX-A) injection into the
quadriceps musculature of the hindlimb. Group 2 (n=5) received unilateral BTX-A injection
into the quadriceps musculature of the hindlimb followed by an exercise protocol. Group 3
(n=5) were control rabbits. The exercise protocol consisted of 400 hops per day on a motorized
treadmill, five days per week, for three weeks.
Outcome Measures: Groups 1 and 3 were analyzed with regards to: 1) Maximal isometric
knee extensor torque (IKET) 2) Quadriceps muscle mass. 3) Gait analysis of ground reaction
forces (GRFs). Histological grading of the cartilage from the knees of Group 2 animals,
comparing the BTX-injected to non-injected leg, was performed in a blinded fashion using the
Mankin Scoring System.
Results: The mean decrease in maximal IKET found when comparing BTX-injected and
control hindlimbs was 68.0 +/- 8.5% (mean +/- S.D.) at four weeks post injection (p<0.01).
This was accompanied by a corresponding 36.3 +/- 4.6% (mean +/- S.D.) decrease in muscle
mass (p<0.01) and a significant decrease in the vertical GRF component of hindlimb push-off
in the BTX-injected hindlimbs. Histological grading of cartilage from the lateral tibial plateau,
lateral femoral condyle and femoral groove of group 2 animals showed significant increases in
cartilage degradation scores in the BTX-injected versus non-injected leg.
Conclusion: Preliminary analysis supports a possible detrimental effect of peri-articular
muscle weakness on cartilage health in the exercised rabbit knee joint.
Glucagon-like Peptide-2 Induces Intestinal Adaptation In Parenterally Fed Rats With
Massive Distal Small Bowel Resection
Osama Bawazir
Pediatric general surgery Division, R7
Co-Investigators: Laurie E. Wallace, Gary R. Martin, Greg Zaharko, Andrea Miller, Ahmad
Zubaidi, David L. Sigalet
Objective: Glucagon-like peptide-2 (GLP-2) is an intestinal trophic peptide which has been
shown to induce adaptation in residual ileum. Herein we investigate the effects on residual
jejunum
Design: Juvenile rats underwent an 80% distal small bowel resection leaving proximal jejunum
anastomosed to colon. Animals were maintained with parenteral nutrition (TPN) and were
randomly assigned to TPN only or TPN + 10 mg/kg/hr of GLP-2. After 7 days in vivo intestinal
permeability was assessed; animals euthanized and intestinal tissue processed.
Outcome Measures: Body weight and small bowel changes, Intestinal Permeability, Intestinal
Morphology and Histology, crypt cell proliferation, crypt cell apoptosis, Nutrient Transporters
(SGLT-1 and Glut-5) and serum GLP2 levels.
Statistical Analysis: All data expressed as means ± SEM. The comparisons among groups
were done using a one-way ANOVA followed by a Tukey-multiple comparison post-test.
Statistical analysis was completed using Graph Pad PrismÒ Version 3.0 software. Results: The TPN + GLP-2 animals had reduced intestinal permeability, increased body
weight, and small intestinal weight, as well as increases in all morphological indices: villous
height, crypt depth, micro-villous height, mucosal surface area, DNA and protein content,
increases in both crypt cell production rate and crypt apoptotic rates but no differences in
intestinal transporter activity.
Conclusions: This study shows that GLP-2 improves intestinal permeability, and stimulates
intestinal adaptation in remnant jejunum. These results suggest that GLP-2 may induce a
clinically useful adaptation following massive distal bowel resection, and also show that
different segments of the bowel have a differential response to exogenous GLP-2.
Reconstruction Following Mastectomy for StageI/II Breast Cancer: A Population Based
Jayson S. Dool, M.D.
Division of Plastic Surgery R-4
Co-Investigators: CJ Doig, AR Harrop, WG deHaas, B Manns
1. To describe the rate of reconstruction in all women diagnosed with Stage I/II breast cancer within the Calgary Health Region between April 1, 1994 to December 31, 2002.
2. To explore possible predictors of reconstruction, both cancer-specific and demographic Design: An observational retrospective population-based cohort study.
Setting: The geographical boundaries of the Calgary Health Region (Region 4) as defined
during the years of study.
Subjects: All women over the age of 18 years having a diagnosis of Stage I or II breast cancer
as recorded within the Alberta Cancer Registry Database.
Outcome Measures: Any form of breast reconstruction, with further determination as to
whether reconstruction was achieved via autologous or implant methods.
Results: A total of 2943 women fitting the inclusion criteria were identified. The overall
incidence of Stage I/II breast cancer was maximal at 3.3/1000/yr. while the absolute number of
cancers was greatest within the 50-64 year old cohort (1021/2943). Initial oncologic surgery
was breast conserving in 68%. Ultimate conservation rate fell to 59% owing to subsequent
mastectomy. Women with documented mastectomy (non-conserving) were deemed to be at
risk of reconstruction (n=1092). In this cohort, a total of 158 reconstructions were performed
for an overall rate of 14.5%. Women under 50 enjoyed a reconstruction rate of 29.5-37.8%,
while in the 50-64 year old stratum, this proportion fell to 11.9%. No differences were seen
with respect to radiotherapy, stage of cancer, nor socioeconomic status (with median
household income serving as a proxy measure of overall socioeconomic status) between the
reconstructed and non-reconstructed groups. Age less than 50 years resulted in a relative risk
of reconstruction of 4.4 as compared to individuals older than 50 years.
Conclusions: The overall breast reconstruction rate in women with documented mastectomy
in our study population was 14.5%. Of the independent variables established in an a priori
fashion, only age appears to be a predictor for breast reconstruction. Of particular note,
reconstruction could not be predicted by socioeconomic status in either univariate nor
multivariate analyses.
THORACIC PARAVERTEBRAL BLOCK IN BREAST SURGERY
Division of General Surgery, R5
Co-Investigators: G. Hollaar, M. Kostash
Objectives:
To determine the safety and efficacy of thoracic paravertebral nerve block(PVB) in reducing post-operative morbidity from pain andnausea/vomiting in patients undergoing breast surgery.
Retrospective chart review, case-control series.
Tertiary Care Hospital.
81 adult patients (80 female, 1 male) undergoing breast surgery requiringgeneral anaesthetic (GA).
42 patients underwent 43 GAs in combination with a PVB, and 39 patientsunderwent 41 GAs without PVB. 17 PVB were unilateral and 26 werebilateral. Complications secondary to PVB. IV/IM analgesic and antiemetic Measures:
requirements in the first twelve hours post-operatively (PARR vs.
Daycare/Ward). Anaesthesia prep time (APT) in the OR, during whichtime PVB would be performed. In the PVB group, two patients developed temporary upper extremityparesthesias and one patient developed a temporary Horner's syndrome.
In the PVB group, 19% required IV narcotics and 23% required anti-emetics in PARR; 19% required IV/IM narcotics and 16% required anti-emetics in Daycare/Ward. In the non-PVB group, 51% required IVnarcotics and 22% required anti-emetics in PARR; 68% required IV/IMnarcotics and 56% required anti-emetics in Daycare/Ward. The medianAPT in the PVB group was 24 minutes for unilateral blocks and 27minutes for bilateral blocks; in the non-PVB group it was 14 minutes.
As an adjunct to general anaesthesia, PVB is a safe and effective way toreduce post-operative pain and nausea/vomiting in patients undergoingbreast surgery.
Epidemiology of Severe Trauma in Status Aboriginal Canadians: A population based
General Surgery R2
Co-Investigators: K Laupland, R Harrop, A Kirkpatrick, L Crowshoe, J Kortbeek, M Hameed
(supervisor)
Background: Aboriginal Canadians are considered to be at increased risk for major
trauma. However, population-based studies characterizing the distribution, determinants
and outcomes of major trauma in these groups are lacking.
Objectives: To measure the impact of ethnicity, as reflected by Aboriginal status, on the
incidence of severe trauma (injury severity score >/= 12) and to broadly define the
epidemiology of severe trauma among status Aboriginal Canadians (SAC) in a large
health region.
Design: Population-based retrospective cohort study involving all adult (=16 years)
residents of the Calgary Health Region between April 1, 1999 and March 31, 2002.
Results: SAC were at much higher risk of sustaining severe trauma than non-SAC (257.2
vs. 68.8 per 100,000; relative risk (RR) 3.7, 95% confidence interval (CI), 3.00-4.61). SAC
were found to be at significantly (all p values < .01) increased risk for injuries resulting
from motor vehicle crashes (RR 4.8), assault (RR 11.1) and traumatic suicide (RR 3.14).
A trend toward higher median ISS scores was observed among SAC (21 vs. 18, p=0.09).
Although the case-fatality rate for SAC people was less than one-half the rate than for
than for non-SAC (14/93 (15%) vs. 531/1686 (31%), p<0.0001), the population mortality
was almost two times that in SAC versus non-SAC (RR=1.8, 95% CI: 1.0-3.0, p=0.046).
Conclusion: Severe trauma disproportionately affects SAC in our health region. The alarming
data should trigger more detailed evaluations of factors contributing to increased risk as a basis
for the rational development of injury prevention programs.
The Buford Complex: Inconsequential Variant or Predisposition to SLAP Lesion
Paul Dooley
Orthopaedic Surgery, R3
Co-Investigators: Dr. Laurie Hiemstra
Objective:
The Buford complex is a variant of shoulder capsulolabral anatomy. Itconsists of an absent anterosuperior labrum and a cord-like middleglenohumeral ligament. It has been considered a normal anatomic variant.
The primary objective is to ascertain whether the incidence of the Bufordcomplex is greater among those with an arthroscopically diagnosed SLAPlesion, than the 1.5% incidence reported to be present among the generalpopulation.
Retrospective chart review Chart review of U of C sport medicine centre patients undergoing shoulderarthroscopy for SLAP lesion during the period 1997 – 2002.
Subjects were identified in the electronic database by diagnostic code forSLAP lesion No specific intervention as the study is retrospective in nature. No directpatient contact.
The primary outcome measure is the incidence of Buford complex asidentified in either the operative report or from review of intra-operativephotographs. Secondary outcome measures include type of SLAP lesionassociated with Buford complex and incidence of SLAP recurrence withBuford Complex.
Results:
The incidence of a Buford complex among those with an arthroscopicallydiagnosed SLAP lesion was significantly greater than that reported to bepresent among the general population (p < 0.05).
The Buford complex is present in a significantly greater proportion ofpatients with an arthroscopically diagnosed SLAP lesion than in thepopulation in general. This "normal" variant of capsulolabral anatomy maypredispose individuals to instability and shoulder pathology such asdevelopment of SLAP lesions.
THE SPECTRUM OF ADRENAL LESIONS ASSESSED IN THE ERA OF ADRENAL
Division of General Surgery, Endocrine Surgical Fellow
Co-Investigator(s): Dr. J. L. Pasieka Background: Incidentally discovered adrenal masses are common as a result of the
widespread use of abdominal imaging. Once identified, adrenals lesion must be characterized
as to their functional status and malignant potential. With the increased use of laparoscopic
adrenalectomies, there is growing concern that surgeons have expanded the indications for
adrenalectomy beyond the traditional large or functioning lesions.
Objective: To review the spectrum of adrenal pathology in a cohort of patients referred to an
Endocrine Surgeon and to assess the indications for surgery in these patients according to their
diagnostic workup.
Methods: Retrospective analysis of all consecutive patients with adrenal lesions referred
from 1992 to 2004. Clinical, radiological and biochemical screening was performed in all
patients. Demographic data, presenting symptoms, functional status, operative and pathologic
findings were collected.
Results: Since 1992, 173 patients with 185 adrenal lesions were assessed. Non-functioning
lesions were found in 52 (30%) patients. Adrenalectomy was performed in 25 (48%) of these
patients with a mean size of the adrenal measuring 5.1 cm (2.2 – 12.5), while 27 patients with a
mean size of 2.4 cm (1.8 – 3.5), with no concerning imaging features were observed. Primary
hyperaldosteronism was found in 43 (25%) of patients. Thirty-five of these patients (81%) had
selective venous sampling (SVS). SVS lateralized disease in 26 (74%), failed to lateralize in 4
(11%) and 5 (14%) had an unsuccessful SVS for technical reasons. Pheochromocytoma was
found in 35 (20%) patients. Sporadic pheochromocytomas were found in 25, familial disease in
6 and paraganglioma syndrome in 4. Malignancy was demonstrated in 2. Cushing's Syndrome
was demonstrated in 29 patients and sub-clinical Cushing's in another 3. Adrenal cortical
adenoma was found in 17, primary hyperplasia in 4, and Cushing's disease in 11. Eleven
patients (6%) had adrenal cortical carcinoma. Non-function was demonstrated pre-operatively
in 7 (63%) of these lesions.
Conclusion: In this surgical series, 70% of the adrenal lesions assessed demonstrated function
and therefore underwent surgical intervention. Non-functioning adrenal lesions were found in
the remaining 30%. 52% of these patients, or 16% of the total group, were found to have small
benign incidentalomas and did not undergo adrenalectomy. The remaining 48% had larger
tumors or suspicious radiographic features that resulted in surgical intervention. Assessment of
function and malignant potential remain the most important indications for surgical
intervention.
TWO TO FOUR YEAR FOLLOW-UP OF A COMPARISON OF HOME VS.
FOLLOWING ACL RECONSTRUCTION
John A. Grant
University of Calgary Sport Medicine Centre, Clinical Clerk
Co-Investigator: N. Mohtadi
Objective: To determine whether or not there were any differences in long-term outcome
between those patients who performed a traditional physiotherapy-supervised rehabilitation
program (PT) and those who performed a primarily home-based rehabilitation program (H)
in the first 3 months following ACL reconstruction.
Design: Long-term prospective follow-up of a cohort of patients from the original
randomized clinical trial (RCT) that evaluated the short-term (3 month post-surgery)
outcomes of the two rehabilitation programs.
Setting: University of Calgary Sport Medicine Centre.
Subjects: Seventy-nine patients (34.6 ± 11.7 yrs) from the original RCT participated.
Interventions: Patients were originally randomized pre-surgery to either a standardized
physiotherapy-supervised (17 physiotherapy sessions) or home-based (4 physiotherapy)
rehabilitation program for the first three post-operative months. Patients were asked to
return 2-4 years following surgery to assess their long-term clinical outcomes.
Outcome Measures: Primary outcome: the Mohtadi ACL condition specific quality of life
questionnaire (ACL QOL). Secondary outcomes: bilateral difference in knee extension and
flexion range of motion, sagittal plane knee laxity (KT arthrometer), relative quadriceps
and hamstrings strength (surgical leg as a percentage of nonsurgical leg), IKDC score.
Statistical Analysis: Continuous data were reviewed for normality with descriptive
statistics. Unpaired t-tests were used to compare the two groups across the continuous
variables. A Chi square test was used for the categorical data. No correction was made for
multiple p values as the study outcome was based on the primary outcome (ACL QOL).
Results: There was no significant difference in ACL QOL score between the groups a mean
of 38 months post-surgery (p = 0.06). The H group demonstrated a higher ACL QOL score
(78.1 ± 16.5) compared to the PT group (69.6 ± 22.9). There were no significant
differences between the two groups with respect to any of the secondary outcome measures.
The group comparisons were as follows: extension difference - PT = 1.4°, H = 2.4°; flexion
difference - PT = 2.3°, H = 1.6°; sagittal plane knee laxity - PT = 2.67mm, H = 1.74mm;
quadriceps strength - PT = 92%, H = 85%; hamstrings strength - PT = 96%, H = 97%;
IKDC ratings - PT = 9A/21B/5C, H = 8A/16B/6C.
Conclusions: This long-term study upholds the short-term findings of the original RCT in
that the home-based rehabilitation program is at least as effective as a more physiotherapy-
intensive program for patients in the first 3 months following ACL reconstruction. Given
the resource savings demonstrated in the original RCT, the home-based program is clearly
Breast Biopsy, Surgical Intervention and Patient Anxiety
Medical Student, University of Calgary
Co-Investigators: Dr. Paul Burrowes, Dr. Bobbie Docktor
Objective: Terms in the American College of Radiology's BIRADS (Breast Imaging
Reporting and Data System) correspond to specific recommendations. Incorrect interpretation
of BIRADS category 3 (a probably benign lesion ( 2% probability of malignancy) with a 6-
month recommended follow-up) may result in inappropriate surgical referrals. The effect of
BIRADS interpretation by physicians on patient management decisions was investigated.
Design, Setting and Subjects: Of all of Calgary area Family Physicians, a random 525 were
sent a 7-section questionnaire by fax and/or mail. Analysis included 199 data sets.
Interventions and Outcome Measures: In this survey, breast biopsy and surgery,
mammography, patient counseling, physician demographics, BIRADS utility and familiarity,
surgical recommendation in various scenarios, and surgical referral were assessed. Physician-
reported patient requests for DI reports and surgical intervention were studied.
Statistical Analysis: The Pearson ÷2 test (+/- Yates' correction) and Pearson's correlation
coefficient were the tests used. Certain 95% CI, means, medians and modes were calculated.
Results: 56% (122) of family physicians are not at all familiar with BIRADS (95% CI 54.5-
68.1%). 47.7% (45.3-59.3%) associate BIRADS 3 with an over 20% probability of
malignancy. 73.2% regularly recommend the suggested 6-month F/U mammogram, but 14%
generally defer to patient wishes. 42.9% (35.9-50%) report that over 20% of patients with a
BIRADS-3 classification elect to undergo biopsy rather than mammography (6 month F/U),
though 76.6% report that women are, in general, comfortable with a 6-month F/U for a
"probably benign" lesion. 34.8% report that over 20% of patients read or copy their
mammography report—a practice not associated with physician-reported patient anxiety.
Years In Practice (avg 18.3, 1-52a, median 17.5) is not associated with any outcome studied.
Reported familiarity with BIRADS and a better understanding of it are not associated. An
understanding of BIRADS-3 is not associated with specific patient management preferences.
The LOS of all ÷2 analysis was 0.05 (2 tailed, 1 df). Physicians in practice for fewer years
reported increased familiarity with BIRADS at a level of significance of 0.10 but not 0.05. All
other comparisons were insignificant even at 0.10 LOS and with Yates' correction.
Conclusions: Interpretation of BIRADS-3 by Calgary family physicians is variable. An
accurate understanding of the BIRAD system should lead to improved surgical and non-
surgical patient management. A change in radiological nomenclature is recommended.
Occipito-Cervico-Thoracic Fusions in Patients with Extensive Cervical Involvement from
G. Swamy, MD, FRCSC
Fellow Spine Surgery; Division of Orthopaedics and Neurosurgery Co-Investigator: RJ Hurlbert, MD, PhD, FRCSC, FACS
Background:
A minority of patients with rheumatoid arthritis experience severe cervical involvement with
atlanto-axial subluxation, basilar invagination and subaxial subluxation.
Interventions:
We have been performing occipito-cervico-thoracic (OCT) fusions in these patients using a
combined anterior/posterior approach, in an attempt to treat all three pathologies definitively.
Methods:
We reviewed the hospital records and office charts of patients undergoing OCT fusion at our
institution from 1997-2003. Seven patients were identified, all with severe rheumatoid
arthritis. Mean follow-up was 24 months. Pre-operatively two patients were classified as
Ranawat I neurologic status, 2 patients were Ranawat II; and 3 were Ranawat IIIb. The
indications for surgery were progressive neurologic deterioration in 5 and intractable neck pain
in 2.
Outcome Measures:
Safety of OCT fusion was determined by tabulating immediate and delayed postoperative
complications. Efficacy of surgery was determined by determining change in Ranawat
neurologic and pain scores after surgery, and fusion rates.
Results:
Surgery involved a staged anterior and posterior approach in all seven patients. The mean total
operative time was 18 hours, with a mean ICU stay of 8 days (range 0-18). Post-operatively 3
patients were Ranawat I neurologic status, 1 was Ranawat II and 2 remained Ranawat IIIb.
Serious complications included CHF, pneumonia, airway obstruction, esophageal dysfunction,
DVT, renal insufficiency, and temporary weakness. All patients experienced significant pain
relief. One patient with non-union died from multi-organ failure following revisional surgery 1
year after the index OCT fusion. Thoracic adjacent segment disease with myelopathy was seen
in one patient, requiring extensive additional thoracolumbar decompression and fusion.
Conclusions:
OCT fusion is an effective method to definitively treat extensive cervical involvement from
rheumatoid arthritis, but surgeons and patients should be aware of the high complication rate in
this difficult population.
A MODIFIED EILBER PROTOCOL PROVIDES MAXIMUM LOCAL CONTROL
AND MINIMUM MAJOR MORBIDITY IN SOFT TISSUE SARCOMA
Dr. Lloyd A. Mack Division of Surgical Oncology, Fellow Co-investigators: W.J. Temple, P.J. Crowe, N.S. Schachar, J.L. Yang, D.G. Morris, E.
Kurien, R.L. Lindsay, E. Magi, W.G. DeHaas
Objective: A local recurrence rate of 15-30% after treatment of soft tissue sarcoma (STS) is
common but unacceptable. Our hypothesis was that a refined neoadjuvant chemotherapy (CT)
and radiation (RT) protocol (modified Eilber protocol) improves local control while
minimizing major morbidity.
Methods: All consecutive patients (pts) presenting with STS deep to the fascia of the
extremity/ trunk during 1984-1996 were treated with 3 days of intravenous (IV) or intra-arterial
(IA) Adriamycin (30mg/day), subsequent radiotherapy (RT) (300cGy/day for 10 days), and
wide surgical excision with limb preservation 4-8 weeks after completion of RT.
Outcome Measures: Resection margins, wound complications, local recurrence and survival
(log rank; Kaplan-Meier) were prospectively documented for a minimum of 5 years or until
death. Prognostic factors were assessed via multivariate analysis (MVA).
Results: 75 patients, including 10 recurrent STS, were analyzed. 51% of cases were of the
proximal lower limb and 23% of the distal lower limb. Mean age was 50 (13-84), 66% had
tumors > 5 cm and 71% were of grade II or grade III. Histologies included liposarcoma
(22.7%), MFH (21.3%), leiyomyosarcoma (16%), synovial cell sarcoma (16%), and other
(24%). Negative margins were not achieved in 8 patients and four of these had amputation
(95% limb salvage). Of the 67 patients with negative margins, a local control rate of 94% and
an overall survival rate of 63% were achieved. Although margin (p=0.001) and stage (p=0.035)
were correlated with LR, these were not significant on regression analysis. Risk factors for
death included TNM stage (Hazard ratio(HR) 1.54;p=0.001) and tumor grade (HR 1.4;p=0.02).
3 pts (4%) required re-operation for tissue loss and 8 pts (10.6%) developed minor wound
complications. There were no in-hospital or thirty-day mortalities.
Conclusion: This modified Eilber protocol is ideal to maximize local control and minimize
complications for STS.
Vertebral Artery Ectasia and PosteriorC1-C2 Transarticular Screw Fixation: Real or
Dr. J.F. Chevalier,
Fellow, Spine Surgery
Co-Investigators: S. Casha, J. Bouchard, R. Cho, P. Salo, S. Du Plessis, R.J. Hurlbert
University of Calgary Spine Program Background: Posterior C1-C2 transarticular screw fixation is an effective method for atlanto-
axial arthrodesis. However, reports suggest restriction of screw insertion due to vertebral
artery (VA) ectasia in 15-20% of trauma patients and in up to 50% patients with rheumatoid
arthritis (RA), arguing for intraoperative navigation. We review our experience in light of
these observations.
Methods: Retrospective case series. Patients undergoing isolated C1-C2 arthrodesis between
1996 and 2003 at our institution were identified and their charts reviewed.
Results: Eighty-nine patients underwent C1-C2 arthrodesis over the 7 year period (n=24 RA,
n=65 non-RA). Indications for surgery included ligamentous laxity and post-traumatic or
congenital instability. In the RA group, 46 of 48 possible C1-C2 transarticular screws were
placed uneventfully (96%). One screw was not attempted because of pre-operatively defined
VAE; one was removed secondary to malposition. In the non-RA group, 126 of 130 possible
screws were inserted uneventfully (97%). Two screws could not be inserted because of marked
kyphosis, one was removed because of malposition, and one fractured the pars interarticularis
without clinical consequence. There were no excluded attempts due to VA ectasia among non-
RA patients, nor known VA lacerations.
Conclusions: Surgeons may be overly sensitive to perceived VA ectasia. In our experience,
safe bilateral transarticular screw fixation is possible in over 95% of RA and in up to 100% of
non-RA patients without vertebral artery laceration or the need for intra-operative navigation.

Source: http://www.calgaryhealthregion.ca/stage/surgicalservices/osr_files/surgeons_day_program_2004.pdf