Canadian Journal of Surgery最新文献

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.

Background: Surgical wait times affect patient outcomes, access to care, and surgeon well-being. The single-entry model (SEM) has been proposed to address these issues, but its implementation raises concerns among surgeons. We sought to explore surgeons' perspectives on surgical wait times, referral processes, and the potential effect of the SEM on improving access to surgical care in a major metropolitan Canadian city.

Methods: We conducted a qualitative descriptive study to explore the perspectives of surgeons at a large community hospital using semi-structured interviews. We used thematic analysis to identify key themes regarding surgical wait times, referral processes, and the SEM.

Results: We interviewed 10 surgeons with different specialties and administrative roles, and a median 16.5 years of experience. Participants expressed frustration with systemic inefficiencies, particularly regarding long wait times for consultations and surgeries. Key issues included overwhelming workloads, limited operating room availability, and nonspecific referrals, which often led to delayed patient care. Surgeons reported burnout from managing these delays. Although many participants viewed the SEM as a promising strategy to improve equitable access to care, others raised concerns about depersonalization of care and reduced surgeon autonomy. Some participants emphasized that, without concurrent reforms to funding models, the SEM could inadvertently reinforce existing disparities, particularly gender-based pay inequities.

Conclusion: Surgical wait times pose substantial challenges for both patient outcomes and surgeon well-being. The SEM holds promise for reducing delays and improving equity in patient access, but its successful implementation requires addressing concerns related to surgeon autonomy and workforce equity.

Background: Thoracic surgeons in Canada responded to the COVID-19 pandemic without existing precedence. The primary aim of this study was to understand how thoracic surgery care in Canada was affected by the pandemic in terms of volume, perioperative management, and patterns of practice.

Methods: Data were obtained using 2 questionnaires (18-item surgeon-specific and 13-item institution-specific questionnaires) in addition to the Canadian Association of Thoracic Surgery (CATS) national database. Outcomes included qualitative surgeon experiences and thoracic surgery volume from March 2020 to December 2022. Centres were separated into 3 levels of COVID-19 burden based on community prevalence.

Results: We received survey responses from 63 surgeons and 6 institutions. In-person consultation dropped by 57% during the pandemic. Preoperative cancer workups experienced minor (≤ 4 wk, 39%) and major (≥ 8 wk, 27%) delays. Operable lung and esophageal cancer experienced minor delays in treatment, while pure ground-glass opacities and benign esophageal pathology experienced major delays (25%) or cancellations (21%). Medical education shifted to virtual platforms, decreasing student involvement by 81%. Perceived factors affecting operating room availability included lack of staff, beds, and personal protective equipment.

Conclusion: There was a pan-Canadian reduction in thoracic surgery volume, regardless of regional COVID-19 caseload. Prioritization of thoracic oncology was observed, with a delay in care for minimally invasive and benign illness. Our findings illustrate how surgeons and institutions responded to the pandemic and inform strategies for Canadian thoracic practice in the event of future analogous events.

Background: Simultaneous bilateral total hip arthroplasty (SBTHA) has been associated with high blood loss and transfusion risk. We sought to analyze the effectiveness of a single intravenous dose of tranexamic acid (TXA) on blood loss and transfusion rates in SBTHA.

Methods: We retrospectively reviewed data from patients who underwent SBTHA with a single dose of TXA (20 mg/kg) before incision. We analyzed hematological parameters and transfusion rates. We performed a multivariate logistic regression analysis to identify independent risk factors for blood transfusion.

Results: We included 92 patients with a median age of 60 (interquartile range [IQR] 52 to 68) years. Of these, 48 (52.2%) were male. The median follow-up time was 4.6 (IQR 3.2 to 7.0) years. Six patients had transfusions, for a transfusion rate of 6.5%. The median hemoglobin levels before surgery, on postoperative day 1, and on the day of discharge were 144 (IQR 135 to 154) g/L, 107 (IQR 93 to 118) g/L, and 101.5 (IQR 90 to 111) g/L, respectively. Longer surgical time (adjusted odds ratio [OR] 1.04; 95% confidence interval [CI] 1.01 to 1.07) and lower preoperative platelet count (adjusted OR 1.01, 95% CI 1.00 to 1.03) were significant risk factors for transfusion. Male sex (adjusted OR 0.04, 95% CI 0.004 to 0.40) and younger age (adjusted OR 0.92, 95% CI 0.86 to 0.99) were protective factors.

Conclusion: We found a low transfusion rate (6.5%) after SBTHA among patients administered a single dose of 20 mg/kg of TXA, with young patients and male patients at lower risk of requiring transfusions. Our results suggest that performing SBTHA with current blood management protocols is effective in patients with bilateral hip disease.