Canadian Journal of Surgery最新文献

SummaryAdvances in the care of surgical patients emphasize the impact of social determinants of health (e.g., age, gender, income, education) on clinical outcomes and the relevance of personalized perioperative care, which can accelerate recovery and reduce complications. The importance of implementing patient-specific health promotion strategies preoperatively is discussed here, and a personalized prehabilitation paradigm that builds on perioperative practices designed to reduce complications and accelerate recovery within the Enhanced Recovery After Surgery (ERAS) approach is proposed. The selected actionable domains of health determinants in this paradigm highlight strategies to optimize surgical patients' health and well-being, by identifying medical and nonmedical vulnerabilities, with the goal of improving surgical outcomes. This discussion will help centre perioperative optimization through health promotion as a core tenet of surgical care.

Background: Second victim syndrome (SVS) is a term encompassing the psychological changes experienced by health care providers after an adverse event, and it is believed that nearly all surgeons experience SVS. We sought to explore SVS experiences of surgeons at our institution and assess the need for a peer support program.

Methods: We distributed a web-based questionnaire to staff surgeons at the University of Toronto, which covered demographics, the validated Second Victim Experience and Support Tool (SVEST), and interest in a peer support program. We performed quantitative assessment to determine at-risk demographics for SVS.

Results: We surveyed 120 participants. Scores on the SVEST were highest in the psychological distress and institutional support domains. There was no difference in scores by gender. General surgeons had higher scores in the turnover intentions dimension. Mid-career surgeons had higher scores in several dimensions. More than half of participants were in favour of a peer support program.

Conclusion: Our results confirm that surgeons at our institution experience SVS, mainly in the form of psychological distress, and that most surgeons are interested in a peer support program. Further research to understand at-risk demographics and characterize survey nonresponders is warranted.

Background: To address the increasing demand and backlog of joint replacements, integrated ambulatory care centres (IACs) are being introduced as a public-private partnership in certain areas of Canada. We sought to assess the safety, effectiveness, and sustainability of an IAC for performing hip, knee, and shoulder replacements and to compare patient outcomes between an IAC and a public hospital.

Methods: We conducted a retrospective analysis of patients who underwent elective arthroplasty surgery at an IAC between Feb. 1, 2023, and Mar. 28, 2024. We matched patients on age, body mass index (BMI), and sex to patients having outpatient surgery at a partner hospital during that same period. The primary outcome was unexpected emergency department (ED) encounters within 1 week of surgery. Secondary outcomes included failure to discharge on the day of surgery, 90-day reoperation rate, and patient-reported outcome measures (PROMs), including the Oxford Hip Score (OHS), Oxford Knee Score (OKS), and Patient-Reported Outcome Measurement Information System (PROMIS) scores.

Results: We included 600 patients who underwent arthroplasty procedures at an IAC (282 hips, 282 knees, and 36 shoulders). The cohort included 318 females and 282 males, with a mean age of 66 years and a mean BMI of 28.7. Of the 600 patients, 16 (2.7%) had an unexpected ED encounter within 7 days, with 2 (0.3%) patients requiring 24-hour admission. At 90 days, 2 (< 1%) patients required admission for reoperation. In the matched cohort of 234 patients, there were no significant differences in unexpected ED encounters at 7 days (3% for IAC v. 5% for public hospital, p = 0.2). The mean improvement in OHS, OKS, and PROMIS (physical) scores was 17.6 (standard deviation [SD] 10.7), 13.1 (SD 11.2), and 8.8 (SD 7.3), respectively, in the IAC group, and 16.1 (SD 12.7), 8.5 (SD 8.9), and 6.2 (SD 7.0), respectively, in the public hospital group.

Conclusion: An IAC for joint replacement is a safe and effective model of improving access for patients requiring joint replacement surgery, with no negative effect on subsequent ED encounters or patient-reported outcomes.

Background: Smokers have increased complications after surgery. We sought to study the feasibility of a structured virtual smoking cessation bundle.

Methods: We conducted a pilot parallel randomized controlled trial involving adult smokers scheduled for elective surgery 1 or more weeks after enrolment. The intervention bundle consisted of an emailed video and brochure, QuitNow referral, and pharmacy referral. The control group received usual care of uncoordinated advice on smoking cessation. Perioperative caregivers, but not participants, were blinded to group allocation. The primary outcome was the participant's self-reported uptake of smoking cessation information and available resources.

Results: We enrolled the target 30 patients (15 intervention and 15 control). The recruitment rate was 0.8 patients/wk; 59% (30/51) of all eligible patients were enrolled. By day of surgery, 1 patient withdrew from the study and 1 was lost to follow-up. The median (interquartile range [IQR]) number of smoking cessation resources used was higher in the intervention group than in the control group on the day of surgery (1 [IQR 1 to 3] v. 0 [IQR 0-1], p = 0.002), 30 days after surgery (1 [IQR 0 to 2] v. 0 [IQR 0 to 0], p = 0.01), and 8 weeks after randomization (1 [IQR 0 to 1] v. 0 [IQR 0 to 0], p = 0.003), but not different at 6-month follow-up (1 [IQR 0 to 1] v. 0 [IQR 0 to 0], p = 0.1).

Conclusion: Patients in the intervention group reported more use of smoking cessation resources than those in the control group. This pilot trial demonstrated that a virtually delivered preoperative smoking cessation bundle was feasible and acceptable to patients.

Trial registration: ClinicalTrials.gov, no. NCT04487548.

Background: Surgeon case conferences (SCCs) involve same-phenotype surgeons (i.e., surgeons who perform similar procedures such as orthopedic or vascular surgeons) meeting to discuss upcoming consecutive cases; other specialties are excluded to ensure a focus on surgical considerations. Given that some studies found that SCCs sometimes led to treatment plan changes among patients with gastrointestinal malignancies, we sought to test SCCs in vascular surgery.

Methods: A pre-study workshop with researchers and vascular surgeons at a single institution produced relevant SCC elements, including the decision to focus on aortic procedures; definitions of major (e.g., convert from open to endovascular approach) and minor (e.g., additional preoperative testing) treatment changes; and an aortic SCC form. The form facilitated collection of data related to the initial treatment plan, the consensus treatment plan, and a description of treatment plan changes. During subsequent SCCs, for each patient, the primary surgeon presented their initial treatment plan, a confidence score for this plan (on a Likert scale of 1 to 5, from no to high confidence), and patient details. Subsequent group discussion produced a consensus treatment plan and a description of any plan changes. Study outcomes included rates of major and minor change from the primary surgeon's initial plan to the consensus plan, and confidence scores for patients with and without a plan change.

Results: Six vascular surgeons from a single academic hospital with a high procedure volume reviewed 100 consecutive patients during 33 aortic SCCs over a 10-month period. The rate of change from initial to consensus treatment plans was 39%. Rates of major and minor changes were 10% and 29%, respectively. Patient and treatment measures were similar for patients with and without a treatment change. Confidence scores for initial treatment plans were similar for patients with and without a change (median score 4 and 5, respectively; p = 0.09).

Conclusion: A structured SCC changed 39% of primary vascular surgeons' initial treatment plans related to aortic procedures, even though confidence scores in initial treatment plans were similar for patients with and without changes. Our results suggest that vascular surgeons should seek structured input from colleagues for all patient cases not just those they perceive as challenging.

Background: Gunshot injuries are a major cause of morbidity and mortality, and evidence shows that violent crimes increased during the COVID-19 pandemic. The aim of this study was to investigate the impact of the pandemic on the prevalence of gunshot injuries and to analyze the demographic characteristics of patients with gunshot injury at a level-1 trauma centre.

Methods: We conducted a retrospective analysis from April 2018 to February 2023. We collected demographic information, injury type, weapon involved, and mechanism of injury. We examined the annual incidence of gunshot injuries to assess the potential influence of COVID-19-related public health measures on rates of violent injury.

Results: We identified 158 patients with gunshot injury. The mean age of patients was 35 (range 18 to 78) years, and 9% were women. Seventy percent were homicide attempts, 8% were suicide attempts, and 20% were unspecified. Weapons used included low-velocity handguns (78%) and hunting rifles (7%), and the remainder were unspecified. There were no injuries from military or other high-velocity firearms. Emergency department patients with hemodynamic shock (18%) were 7.5 times more likely to die before discharge than stable patients (29% v. 4%). Gunshot injuries significantly increased by 52% during the COVID-19 period compared with the baseline period (p = 0.03). After the COVID-19 period, injuries significantly decreased (p = 0.048), returning to levels statistically indistinguishable from the baseline period (p = 0.7). Seasonal variation analysis confirmed significant peaks during the summer and early autumn months.

Conclusion: This study highlights the impact of the COVID-19 pandemic on gun violence, with a significant increase in the number of firearm injury victims during this period. Our findings show a return to prepandemic baseline levels in 2022.

Background: Rising health care expenditures and dissatisfaction with traditional models of reimbursement have driven an interest in alternative payment model (APM) initiatives. Bundled funding, an APM, was implemented province-wide for elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) in Ontario in 2019. In this study, we explored whether procedure volume, quality of care, and cost were affected by the program's introduction.

Methods: In this retrospective cohort study, we developed pre- and postimplementation patient cohorts with aggregate data collected from the Canadian Institute for Health Information (CIHI) and Canadian Joint Replacement Registry. We assessed quality via length of stay, 30-day readmissions, emergency department visits, and revision surgeries. We assessed costs using methodology and data provided by CIHI. We performed statistical analysis by comparing patient cohorts via χ² and Student t tests.

Results: After the introduction of the bundle, case volume increased, length of stay decreased, and more patients were discharged directly home following surgery (p ≤ 0.001). Patients with THA were less likely to be readmitted or visit the emergency department in the postbundled cohort (p ≤ 0.009). Despite a reduced length of stay, the cost of THA and TKA increased, with $106 more being spent per patient (p ≤ 0.001).

Conclusion: The introduction of bundled funding for THA and TKA in Ontario was associated with preserved quality of care despite shorter lengths of stay in hospital and reduced use of inpatient rehabilitation. Although cost containment is often a goal of bundled funding, Ontario's model saw a rise in inpatient surgical costs. A shift to outpatient arthroplasty could yield significant cost savings under the current bundle design.

Background: Pediatric patients from remote Indigenous communities in northern Quebec face substantial challenges accessing surgical care, often requiring lengthy air travel to urban hospitals. We sought to quantify time spent away from home for surgical care and explore telemedicine use during the perioperative period for this population.

Methods: We conducted a retrospective chart review of children from Nunavik and Terres-Cries-de-la-Baie-James who received surgical care at the Montreal Children's Hospital between 2011 and 2021. Dates of preoperative consultation, surgery, and postoperative follow-up were recorded, along with encounter modality.

Results: Of 914 patients identified, 40.9% required urgent surgery. For elective procedures, 59.1% of patients waited 14 days or longer for surgery after initial consultation. Postoperatively, 46.8% had follow-up appointments within 7 days of discharge, while 26.1% waited more than 14 days. Telemedicine was used in only 2.2% of elective consultations and 5.5% of follow-up appointments.

Conclusion: Wait times for surgery and initial follow-up appointments often exceeded 2 weeks and required return trips to Montréal, while telemedicine adoption remained limited across departments. Efforts to reduce wait times, increase telemedicine adoption, and enhance culturally safe practices could improve access and care experiences for patients from northern Quebec.

Background: Despite numerous randomized controlled trials finding that albumin is not associated with improved patient outcomes, transfusion practice is highly variable. We examined the variability and impact of albumin transfusion on outcomes in cancer surgery.

Methods: We included consecutive adults undergoing cancer surgery between 2018 and 2021 in Ontario, Canada. The primary exposure was the proportion of patients who received perioperative albumin. The secondary outcomes were hospital length of stay and the incidence of infection, anemia, venous thromboembolism, and mortality in albumin-treated versus non-albumin-treated patients in a case-control analysis.

Results: Of 155 166 cancer surgeries (66.8% female patients, median age 62.9 yr), 2.5% received perioperative albumin. The cancer surgery types with the highest proportion of patients receiving albumin were hepato-pancreato-biliary (24.8%) and colorectal (18.6%). Of 104 facilities, 12.5% had nonrandom outliers for albumin use in at least 1 cancer type (p = 0.0004). Patient outcomes were different in case-control matched cohorts for colorectal and hepato-pancreato-biliary surgeries, including a higher rate of infection, venous thromboembolism, and mortality in patients treated with albumin (cases) than those who were not (controls).

Conclusion: Albumin transfusion rates were highly variable among hospitals for the same cancer type. Quality improvement initiatives are warranted to curtail unnecessary albumin transfusions in the perioperative period.