Canadian Journal of Surgery最新文献

SummaryAlthough blood transfusion as a clinical practice dates back several centuries, the optimal approach remains controversial. In the last decade there has been renewed interest in whole blood transfusion over component therapy for trauma patients. A recent multicentre prospective study assessed the impact of whole blood resuscitation on survival among injured patients in hemorrhagic shock presenting to trauma centres in the United States. We have undertaken an Evidence Based Review in Surgery of that study to appraise how its authors tackled an important clinical question with increasing relevance in modern trauma practice: What is the role of whole blood in trauma resuscitation?

Background: Given that diagnostic, neoadjuvant treatment, and surgical approaches to rectal cancer have changed markedly in the last 25 years, knowledge translation (KT) may be useful to optimize rectal cancer surgery and improve patient outcomes. We sought to evaluate the impact of surgeon-directed KT to improve the quality of rectal cancer surgery on local tumour recurrence in Ontario.

Methods: Ontario's 14 health regions were previously categorized into 2 high-intensity and 12 low-intensity KT regions, based on KT methods (e.g., theory, audit, feedback), applied from 2006 to 2012 to improve the quality of rectal cancer surgery. In the high-intensity regions, efforts encouraged preoperative magnetic resonance imaging, appropriate radiation, and optimal surgical technique. We abstracted hospital chart data from across Ontario for a random sample of cases from 2010 to 2012 based on the respective population of a region and the relative hospital case volume within their region. The main study outcome was local tumour recurrence.

Results: In the high-intensity and low-intensity KT regions, we reviewed data from 523 (48.6%) and 557 (51.4%) patients, respectively. Descriptive variables (e.g., age, sex, tumour stage) were similar between groups. In the high- and low-intensity regions, the proportion of patients with a permanent stoma was 31.4% and 26.4% (p = 0.08), the proportion with positive radial margins was 8.0% and 6.1% (p = 0.2), and the proportion with local tumour recurrence was 6.3% and 5.2% (p = 0.2), respectively. The adjusted risk of time to local recurrence was similar in the high- and low-intensity KT regions (hazard ratio 0.72, 95% confidence interval 0.50-1.05).

Conclusion: The use of resource-intense methods was not associated with improved patient outcomes, including local tumour recurrence. New approaches are needed to optimize the population-level quality of rectal cancer surgery.

Background: Outpatient overprescribing of opioids in the postoperative period contributes to the opioid epidemic. Given that patient education and evidence-informed prescription protocols have reduced postoperative opioid use in small, randomized trials, we sought to evaluate the effectiveness of a multimodal opioid reduction protocol, implemented institution-wide at an outpatient Canadian orthopedic surgery centre.

Methods: In this pre-post intervention study, we used deidentified health administrative data from a provincial data repository to identify all opioid-naive patients who underwent outpatient shoulder or knee surgery at a single institution between 2013 and 2022. An opioid restriction protocol was implemented in 2019, including an educational pamphlet, perioperative verbal education, and a standardized postoperative analgesic prescription. Outcomes analyzed included dispensed morphine milligram equivalents (MME) per patient within 180 days of surgery and chronic opioid use, defined as opioids dispensed 180-270 days after surgery. Prescriptions dispensed from any provider were included.

Results: We included 8244 patients preintervention and 2205 patients postintervention in the analyses. The average MME dispensed per patient decreased by 18% (57.8 MME, 95% confidence interval 45.0-70.6). The proportion of patients who filled opioid prescriptions beyond 180 days after surgery decreased from 4.8% to 2.6% (p < 0.001). These findings remained consistent after adjustment for age, sex, socioeconomic status, mental health, and medical comorbidity in multivariable regression analyses.

Conclusion: The volume of opioids dispensed and the number of chronic opioid users were significantly reduced among patients who underwent outpatient orthopedic surgery after the institution-wide implementation of a multimodal postoperative opioid reduction protocol.

Background: Many rural communities have lost local access to procedural care, and although rural surgical services have endured in some regions, questions regarding quality and safety of care have persisted. Using retrospective observational data, we sought to compare adverse outcomes of the most common surgical procedures performed at rural facilities in British Columbia and outcomes by provider specialty. Our objective was to show whether the efficacy of surgical care at rural facilities is comparable to that of larger referral facilities and whether family physicians with enhanced surgical skills (FPESS) have outcomes comparable to those of specialists at referral facilities for low-morbidity patients.

Methods: We included patients who had a colonoscopy, hernia repair, appendectomy, or cesarean delivery at 1 of 7 rural hospitals in BC that participated in the Rural Surgical and Obstetrics Networks of BC and corresponding referral facilities between 2016 and 2021. To control for differences in the acuity of patients between facility types, we risk stratified data by patient comorbidity level, in addition to adjusting for other demographic differences using multivariable Firth logistic regression analysis. We also compared the outcomes of FPESS with those of regional specialists for low-acuity patients in a similar manner. We calculated adjusted odds ratios (ORs), used tests of noninferiority to obtain p values for the adjusted ORs, and calculated E-values to estimate the extent to which our findings could be due to other unmeasured confounding.

Results: Most surgical procedures at rural hospitals were performed by FPESS (n = 4403, 34.9%) and visiting general surgeons (n = 7317, 57.9%). We found that the quality of care at rural facilities was at least equivalent to the quality at referral facilities in rural BC for colonoscopy, hernia repair, and appendectomy, and that FPESS had outcomes at least equivalent to those of specialists for low-acuity patients.

Conclusion: Our findings provide evidence in favour of the efficacy of rural procedural care at BC facilities, and although these results are not inherently generalizable to other populations, we believe they illustrate the potential for high-quality rural care for low-acuity procedures in similar settings. These findings are an important step toward documenting rural-specific outcomes and creating attendant benchmarks for rural practice.

Background: Although fluoroscopy is used routinely, surgeons and orthopedic residents are inadequately educated about the dangers associated with radiation exposure and protective measures in the operating room. We sought to report the average radiation exposure during common orthopedic trauma procedures for different team members and to determine if the fluoroscopy emitting report is correlated with the radiation measured in the room.

Methods: We conducted a prospective observational study over 3 months in a level 1 trauma centre. We collected radiation levels from dosimeters in different standardized locations at 1 m, 2 m, and 3 m from the C-arm machine, labelled as dosimeters A, B, and C, corresponding to the locations of the surgeon, anesthesiologist, and nurse, respectively). We classified mean exposure (and standard deviations [SDs] according to the body part exposed and the dose delivered.

Results: We included recordings from 100 patients who underwent surgery for fractures, of which 50 involved a distal extremity, 31 involved a proximal extremity and 19 involved the pelvic area. Dosimeter A (surgeon) recorded a significantly higher amount of radiation at a mean of 20.35 (SD 54.25) μSv than the other 2 dosimeters (B [anesthesiologist]: 0.87 [SD 1.55] μSv; C [nurse]: 0.49 [SD 0.92] μSv), regardless of the fracture location. Higher radiation levels were recorded for fixation of centrally located fractures, followed by lower-extremity fractures and upper-extremity fractures. Half-dose and quarter-dose fluoroscopy emitted statistically lower radiation than standard-dose fluoroscopy. The radiation report from the fluoroscopy machine was highly correlated with the measured radiation (ρ = 0.93; r ² = 0.909, p < 0.001).

Conclusion: Radiation exposure is much higher closer to the fluoroscopy machine and decreases following an inverse-square law from the radiation source, becoming negligible at 2 m from the source. Using the low-dose radiation mode can significantly decrease radiation exposure.

Background: An increasing number of total knee arthroplasties (TKAs) are performed in people with obesity, but TKAs in this population may come with increased risk of perioperative complications and decreased prosthetic survivorship. Given the lack of conclusive evidence on differences in functional outcomes, we aimed to use the Forgotten Joint Score-12 (FJS-12) to see how body mass index (BMI) affected functional outcomes after TKA.

Methods: We recruited patients who underwent primary unilateral TKA because of osteoarthritic changes from January 2018 to November 2021. We collected the Forgotten Joint Score-12 (FJS-12) measure of functional outcomes and the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) preoperatively and 6- and 12-months postoperatively. We also measured length of stay (LOS), readmission, and emergency department (ED) visits. We compared outcomes by BMI category using linear effects models.

Results: We recruited 351 patients. No differences were found in LOS, readmissions, and ED visits by BMI category. Compared with the preoperative score, we observed significant differences by BMI category for the 6-month FJS-12 (β = -0.66, p = 0.007) and 12-month WOMAC (β = -0.34, p = 0.02) scores. At 6 months, patients with lower BMI showed a greater change in FJS-12 scores than those with higher BMI. However, by 12 months, all patients appeared to return to similar functional levels regardless of BMI.

Conclusion: Despite a slower return to function, patients with elevated BMI were able to return to similar levels of function as those with a lower BMI by 12 months, with no significant differences in readmission, ED visits, or LOS. This similar return to function justifies candidacy for surgery.

Background: About 1%-2% of pregnant patients develop conditions that require emergency general surgery (EGS). The diagnosis and management of these conditions can be challenging, as surgeons must carefully balance the needs of the pregnant patient and the developing fetus. We sought to summarize the latest literature guiding surgical management of appendicitis, benign biliary disease, bowel obstruction, and hemorrhoids in pregnant patients.

Methods: We performed a comprehensive scoping review using OVID Medline for articles published between January 2000 and June 2023 pertaining to EGS and pregnancy.

Results: Acute appendicitis, benign biliary disease, and bowel obstructions confer increased risk of adverse maternal and fetal obstetrical outcomes. In general, pregnant patients with acute appendicitis and cholecystitis should undergo appendectomy or cholecystectomy, respectively. The management of biliary colic has significant nuance depending on trimester. While an operative approach is favoured in the first 2 trimesters, the role of surgery in the third trimester is less clear. Nonoperative treatment of each of these diseases can result in significant maternal, and possibly fetal, morbidity. Operative management of bowel obstruction must be determined on a case-by-case basis. In all instances, a laparoscopic approach is preferred, if feasible.

Conclusion: A thoughtful approach is crucial for surgeons and institutions caring for pregnant patients with EGS diseases. Treatment should be similar to that in nonpregnant patients, with some important considerations and modifications. Nonoperative or delayed operative management often increases adverse obstetrical events, including death.

Background: Research examining the impact of different models of care on wait times for breast cancer surgery indicates that organized assessment can reduce wait times, but few researchers have explored different care approaches between care sites serving a mixture of urban and rural patients and breast cancer care outcomes, especially within the Canadian context. Therefore, we sought to explore whether wait times from mammogram to surgery differed between lean referral and traditional referral pathways and what areas of inefficiencies need to be addressed.

Methods: We used a retrospective case review design and collected information on female patients (aged ≥ 19 yr) with stage 0-III breast cancer who were surgically treated between February 2016 and July 2019.

Results: Patients referred in the traditional pathway of care (n = 208) had longer wait times than patients in the lean pathway of care (n = 248), with an average wait time difference of 9.3 days. For both care pathways, receiving a screening mammogram, living farther from the hospital, and receiving magnetic resonance imaging (MRI) increased wait times to surgery.

Conclusion: Conducting the biopsy immediately after an abnormal mammogram, improving wait times for MRIs, and improving access for rural patients may be important areas of change-related focus. Shorter wait times to breast cancer surgery in the lean pathway support the advantage of a referral system whereby organized navigated systems coordinate all aspects of diagnosis and treatment.

Background: Indigenous Peoples in Canada have higher obesity rates (30%-51%) than non-Indigenous populations (12%-31%), and the Truth and Reconciliation Commission of Canada (TRC) has called for expanded health research to address disparities between Indigenous and non-Indigenous communities. We sought to compare bariatric surgery outcomes and patient experiences in Newfoundland and Labrador's bariatric surgery program among Indigenous versus non-Indigenous patients.

Methods: We conducted a mixed-methods retrospective cohort study, including patients who underwent bariatric surgery in the province's bariatric surgery program between 2011 and 2022. We assessed metabolic outcomes through chart review and captured patient experiences with phone survey questionnaires.

Results: Among the 30 included patients (8 Indigenous, 22 non-Indigenous), there were no significant differences in excess weight loss (45% v. 48%, p = 0.4), reduction in body mass index (9.5 v. 11.3, p = 0.2), comorbidity improvement (63% v. 73%, p = 0.6), or postoperative complications (25% v. 18%, p = 0.6) at 1 year. However, on a 1-10 Likert scale, Indigenous patients reported lower satisfaction with weight loss (6.3 v. 8.2, p = 0.03) and were less likely to recommend the program (5.6 v. 8.8, p = 0.04). Both groups cited similar challenges with program referral, transportation, and postoperative supports, and recommended a longer follow-up period and increased mental health counselling services.

Conclusion: As a response to TRC's Calls to Action, our study shows bariatric surgery outcomes in Newfoundland and Labrador were similar for Indigenous and non-Indigenous patients. Given their lower satisfaction with postoperative decrease in weight, Indigenous patients may benefit from being offered metabolic procedures with greater expected weight loss, such as Roux-en-Y gastric bypass and duodenal switch.