Canadian Journal of Surgery最新文献

Background: Although surgical outcomes among octogenarian patients are well documented, evidence for nonagenarian patients is limited. We sought to compare surgical outcomes between these age groups to guide clinical decision-making.

Methods: We conducted a retrospective cohort study (2013 to 2023) with 1:1 propensity-score matching. We included patients aged 80 to 99 years who underwent general surgery. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 90-day and 1-year mortality, functional status at last follow-up, complications (Clavien-Dindo classification), and hospital readmissions.

Results: From 700 screened patients aged 80 to 99 years who underwent general surgery, 174 met inclusion criteria (73 nonagenarian and 101 octogenarian patients), yielding 73 matched pairs for analysis. Nonagenarian patients had significantly higher 30-day mortality (26.0% v. 9.6%, p = 0.02), 90-day mortality (49.3% v. 23.3%, p = 0.002), and 1-year mortality (75.3% v. 39.7%, p < 0.001) than octogenarian patients. At last follow-up (median 11 to 12 mo), poor functional status was observed in 34.2% of nonagenarian versus 23.3% of octogenarian patients. Hospital readmissions within 30 days occurred in 42.5% of nonagenarian versus 21.9% of octogenarian patients (p = 0.002). Despite propensity matching, the Fried frailty phenotype remained significantly imbalanced between groups (standardized mean difference 0.714, p < 0.001).

Conclusion: Nonagenarian patients face substantially worse surgical outcomes than octogenarian patients, with nearly triple the 30-day mortality and high rates of functional impairment among survivors. The persistent frailty imbalance despite matching suggests inherent selection bias in surgical nonagenarians. Unlike octogenarians, for whom selective surgery may be justified, these findings support careful consideration of nonoperative management as the default approach for nonagenarians, with surgery reserved for highly select cases after comprehensive geriatric assessment and thorough shared decision-making with the patient.

SummaryThe relocation of appropriate gynecologic procedures, such as diagnostic and operative hysteroscopy, from the operating room to an ambulatory setting meets all 3 arms of Kissick's "Iron Triangle": providing quality care with improved access without an associated increase in cost to the system.

Background: Screening for colorectal cancer reduces mortality by enabling early detection. In Quebec, follow-up within 60 days after an incomplete colonoscopy is recommended. In this study, we sought to assess the impact of delays in follow-up on patient outcomes.

Methods: In this retrospective study, we included adults who underwent a colonoscopy following a positive immunochemical fecal occult blood test at the Centre intégré universitaire de santé et de services sociaux de l'Estrie-Centre hospitalier de l'université de Sherbrooke between Jan. 1, 2013, and Dec. 31, 2015. We verified colonoscopy adequacy and guideline adherence. We classified advanced polyps and colorectal cancer as clinically significant lesions (CSLs) to assess the clinical impact of incomplete or missing follow-up colonoscopies.

Results: In 89 cases of incomplete colonoscopies, inadequate bowel preparation was the leading cause of exam interruption (61.8%). A total of 57 patients had a subsequent follow-up, and 23 colonoscopies were completed within the 60-day time frame. Six CSLs, including advanced polyps and cancer, were detected within the recommended 60-day time frame, and 4 were identified after 60 days. We found a statistically significant difference in the rates of colorectal cancer diagnosis (p < 0.001), the need for surgery (p < 0.02), and death (p < 0.001) between patients who had a complete colonoscopy diagnostic process and those who did not.

Conclusion: The poorer prognosis associated with patients who had a delayed or missing follow-up highlights the importance of respecting provincial guidelines concerning follow-up after incomplete colonoscopies.

Background: Major upper-extremity amputation, defined as loss above the wrist, profoundly affects all aspects of life and imposes substantial health care burdens. Standard care involves prosthetics, which have limitations, while vascularized composite allotransplantation (VCA) offers improved functionality but raises cost-effectiveness concerns. We sought to evaluate health care use and cost of major upper-extremity amputation in Ontario.

Methods: We conducted a 20-year retrospective matched-cohort study using administrative health care data from Ontario. We matched patients with major upper-extremity amputations (April 2002 to March 2023) 4:1 with general population and hospital-based trauma controls. We analyzed health care use and costs by follow-up duration (1 yr, 1 to 4 yr, 5 to 9 yr, > 10 yr).

Results: We identified 617 patients with a mean follow-up of 6.95 years, including 41.7% with traumatic amputations and 58.3% with nontraumatic amputations. Forearm-level amputations were most common. Median health care costs were $52 661 (interquartile range [IQR] $22 009 to $120 120) for traumatic amputations and $90 928 (IQR $43 128 to $213 034) for nontraumatic amputations, both exceeding controls. Bilateral amputations incurred higher costs than unilateral amputations ($104 895 [IQR $41 290 to $243 967] for traumatic and $117 006 [IQR $68 447 to $226 491] for nontraumatic cases), excluding prosthetics. Total treatment costs with myoelectric prosthetics exceeded $344 895 for patients with bilateral amputations and $171 860 for those unilateral amputations, surpassing prior projections.

Conclusion: Although lifetime VCA costs remain higher than for prosthetics, the lack of Canadian utility measures, societal cost data, and return-to-work outcomes underscores the need for further study to assess whether the functional and quality-of-life benefits could justify these expenditures for patients with bilateral amputations.

Background: Immigrants are susceptible to marginalization within health care systems, and breast reconstruction after mastectomy is a procedure prone to disparities in delivery. We sought to measure differences in immediate and delayed reconstruction between immigrant and nonimmigrant females with breast cancer in urban Ontario, Canada.

Methods: We conducted a retrospective population-based study using linked administrative databases held at ICES. We included female patients with stage I to III breast cancer, diagnosed from January 2010 through April 2016, who were treated with mastectomy. We excluded those with in situ disease only, missing staging data, another cancer diagnosis, no provincial health coverage, or rural residence. We categorized patients as immigrants if they arrived in Canada from 1985 onward. We compared the proportions of immigrants and nonimmigrants who underwent breast reconstruction.

Results: We identified 2174 immigrants and 12 052 nonimmigrants. Immigrants were younger (mean age 53.3 yr v. 62.2 yr) and more often had stage III disease (32.8% v. 29.7%). They were less likely to undergo reconstruction (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.48 to 0.62). In stratified analyses by age (< 50 yr and ≥ 50 yr), compared with nonimmigrants, the odds ratio for reconstruction was 0.51 (95% CI 0.44 to 0.60) in immigrants younger than 50 years and 1.12 (95% CI 0.94 to 1.30) in those aged 50 years and older. The difference between groups was more pronounced for delayed (OR 0.48, 95% CI 0.41 to 0.56) than immediate (OR 0.83, 95% CI 0.68 to 1.00) reconstruction. Immigrants were less likely to undergo reconstruction regardless of disease stage. Those from East Asian or Pacific, South Asian, and sub-Saharan African regions were least likely to undergo reconstruction.

Conclusion: Immigrant females were less likely to undergo breast reconstruction than nonimmigrant females. This study identified subgroups for further research to understand how to ensure equitable access to this important health care resource.

Background: In this study, we sought to characterize the epidemiologic features of trauma in Eeyou Istchee and describe outcomes for patients referred to our institution. Our primary objectives were to better define the regional burden of injury, identify potentially hidden trauma mortality, and explore opportunities for injury prevention and trauma system optimization in this unique setting in northern Quebec.

Methods: We conducted a retrospective review of our institutional trauma registry, identifying all trauma patients transferred to the Montreal General Hospital from Eeyou Istchee between 2012 and 2022. We extracted and analyzed patient demographics, mechanisms of injury, and outcomes. We also reviewed the coroner's reports for all trauma-related deaths in Eeyou Istchee over the same period. We used descriptive statistics for analysis.

Results: A total of 587 patients (aged 18 to 91 yr) were transferred, including 353 males (60.1%) and 234 females (39.9%). The highest number of transfers (n = 84, 14.3%) occurred in 2022. The most common mechanisms of injury were blunt trauma (n = 228, 38.8%) and falls (n = 163, 27.8%). We also observed motor vehicle collisions (n = 103, 17.5%) and penetrating trauma (n = 50, 8.5%), while 17 cases (2.9%) involved other mechanisms, and 26 (4.4%) were of unknown origin. Assault was reported by 211 (35.9%) patients. Of all patients, 146 (24.9%) were admitted, and 441 (75.1%) were discharged from the emergency department. Computed tomography was performed for 376 patients (85.3%), among whom 222 (59.0%) patients had no injuries identified. Coroner data identified 82 trauma-related deaths, including 61 males (74.4%) and 21 females (25.6%). Motor vehicle collisions were the most common cause of death (n = 23, 28.0%). The trauma-related mortality rate in Eeyou Istchee was 47.8 per 10 000 population, compared with 27.8 per 10 000 in the rest of Quebec, yielding a relative risk of 1.72.

Conclusion: There is a marked disparity in trauma-related mortality between Eeyou Istchee and the rest of Quebec, with motor vehicle collisions representing the leading cause of trauma death. Strengthening partnerships with local communities in Eeyou Istchee is essential to enhance awareness, promote injury prevention, and improve trauma system effectiveness in the region.

Background: Pneumonectomy has long been shown to be curative for lung cancer but may lead to several acute and chronic adverse physiologic changes. Limited data are available on long-term follow-up of patients who have undergone this procedure. We sought to evaluate whether pneumonectomy is still a valuable therapeutic procedure when it is the only curative approach available and to report on long-term survival after the procedure as well as operative mortality and morbidity.

Methods: The primary outcome of our study was long-term overall survival after pneumonectomy. Secondary outcomes were operative mortality and morbidity at 30 days and 90 days, and identification of risk factors influencing operative mortality and overall survival. We conducted a single-institution retrospective study involving all patients who underwent a pneumonectomy for non-small cell lung cancer between Jan. 1, 2005, and Dec. 31, 2019.

Results: We included 277 patients; 59.6% were male and the mean age was 64 years. The median survival time was 3.2 years. Overall survival rates at 1, 5, 10, and 15 years were 73.3%, 42.8%, 29.7%, and 26.3%, respectively. Univariate and multivariate analyses on survival showed that age, tobacco exposure, advanced oncologic stage, and bronchopleural fistula were associated with a worse prognosis. Mortality at 30 days and 90 days was 6.5% and 11.2%, respectively. Neoadjuvant therapy and right-sided pneumonectomy did not increase the risk of death, whereas intrapericardial pneumonectomy, pulmonary complications, atrial fibrillation, and bronchopleural fistula did increase it.

Conclusion: Pneumonectomy remains a valuable therapeutic option when treating patients with non-small cell lung cancer with a curative intent with regard to their overall survival, but it remains a procedure with high perioperative morbidity and mortality.

Background: Operating rooms (ORs) produce more than 30% of a hospital's total waste, with plastic accounting for 20% of that waste. Our project aimed to reduce OR plastic waste by encouraging patients at London Health Sciences Centre sites to bring reusable bags for their belongings and reusable water bottles.

Methods: We used the Plan-Do-Study-Act (PDSA) quality-improvement method, conducting 3 PDSA cycles, first at Nazem Kadri Surgical Centre, and then at Victoria Hospital and University Hospital. Educational interventions informed staff and encouraged patients to bring their own reusable items. Outcome measures included environmental carbon footprint savings, waste savings, and cost savings over a 1-year period. Process measures included the percentage of patients who brought their own reusable bags and water bottle, the percentage of plastic belongings bags purchased, and the percentage of patients informed to bring their own reusables. Balancing measures assessed patient satisfaction and administrative workflow changes.

Results: In PDSA cycle 3 at University Hospital and Victoria Hospital, 60.0% and 78.0% of patients brought their own reusable bags for belongings, and 15.7% and 57.8% brought a reusable water bottle. There was a 45.7% reduction of plastic bags for patient belongings purchased annually, which equated to a reduction of 2141 kg of carbon dioxide equivalents, 10 393 km driven equivalent emissions, $1259.55 saved, and 252 kg of waste saved. Most patients and staff agreed that bringing reusable bags for surgery is easy.

Conclusion: This quality-improvement initiative achieved high patient uptake of reusable items and resulted in substantial reductions in plastic use, waste, and associated carbon emissions. Transitioning to reusable bags for patient belongings and reusable water bottles is an environmentally friendly initiative to reduce the carbon footprint of an OR.

Background: Timely access to care after rotator cuff tear is an important factor in treatment success. We sought to determine the relationship between socioeconomic status (SES) and time to treatment among patients who underwent rotator cuff repair (RCR) in a publicly funded health care system, including time from general practitioner diagnosis to orthopedic consultation (T1) and time from orthopedic consultation to surgery (T2).

Methods: We conducted a retrospective, population-based cohort study using data from the Manitoba Population Research Data Repository. We calculated T1 and T2 for all patients who underwent RCR between 1990 and 2020. We compared times between SES levels as defined using the Socioeconomic Factor Index-2 (SEFI-2). We compared SES level between surgical and nonsurgical patients with rotator cuff injuries between 2015 and 2020.

Results: There were no significant differences in T1 and T2 by SES level (p = 0.4 and p = 0.2, respectively). The odds ratio of having surgery within 1 year after consultation for patients in the lowest SES category was 0.70 (95% confidence interval 0.52 to 0.94) compared with patients in other SES categories. The mean SEFI-2 was -0.21 for surgical patients and -0.03 for nonsurgical patients (p < 0.001).

Conclusion: In a publicly funded health care system, patients with lower SES were less likely to undergo RCR than those with higher SES. The odds of waiting longer than 1 year for surgery from the time of orthopedic consultation were greatest among patients with the lowest SES.

Background: Continuous pressure measurement of traumatized muscle has been shown to be an accurate method of diagnosing acute compartment syndrome (ACS), but no baseline data have been released to show the reaction to surgery in extremity fracture. We sought to establish normal values for perioperative pressures.

Method: We obtained pressure tracings from prospective clinical trials of forearm and tibia fractures requiring surgery. We standardized data and produced graphs using the ggplot2 library in R version 4.2.2. We generated generalized pressure curves based on the mean pressure and quantile distribution for each time point.

Results: We retrieved data from 79 preoperative and 50 postoperative patients. The mean age was 43 years in both groups. Patients exhibited higher pressures postoperatively whether or not they developed ACS. In both the preoperative and postoperative ACS groups, muscle pressure trended upward at an average rate of 0.078 and 0.073 mmHg per hour, respectively, but trended downward in non-ACS groups, at a rate of 0.24 and 0.27 mm Hg per hour pre- and postoperatively, respectively. Patients younger than 45 years registered the highest initial postoperative pressure. Postoperative initial pressures were higher than preoperative pressures and were higher among males than females. Females had steeper decreasing pressure curves in both pre- and postoperative scenarios.

Conclusion: We observed trends in muscle pressure by sex, age, and diagnosis of ACS among trauma patients. Understanding these variations is essential for improving timely diagnosis of ACS.