Canadian Journal of Surgery最新文献

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.

Background: The Surgical Safety Checklist (SSC) is a communication tool used to improve patient safety and teamwork within operating rooms. Unlike the sign-in and timeout phases, the timing for completion of the sign-out phase is ambiguous, lacks a clear and definitive clinical anchor on when to be performed, and fails to capture important safety data related to the patient's emergence from anesthesia, wherein the risks of complications are greatest. We sought to assess perceptions of operating room team members on whether emergence from anesthesia is an appropriate clinical anchor to conduct the SSC sign-out phase.

Methods: In this single-centre proof-of-concept quality-improvement study, the sign-out phase of the SSC was performed following patient emergence from anesthesia. Operating room team members from surgery, anesthesiology, and nursing were approached to complete a self-administered questionnaire. Participants were asked whether, compared with routine sign-out performance, performing the sign-out phase following emergence from anesthesia maximized patient safety, compliance, communication, team member availability, and quality improvement. Responses were graded on a 5-point Likert scale.

Results: Eighty-two operating room team members participated in our study. After experiencing the intervention, most participants agreed or strongly agreed that performing the sign-out phase following emergence from anesthesia maximized patient safety (70.7%), compliance (67.1%), communication (75.6%), and quality improvement (67.0%). More than half agreed that performing the sign-out following emergence from anesthesia maximized team member availability (59.8%).

Conclusion: This proof-of-concept quality-improvement study suggests that emergence from anesthesia is an appropriate clinical anchor for the time to perform the SSC sign-out phase.

Background: The introduction of rentable electric scooters (e-scooters) has been associated with injury presentations to emergency departments (EDs). Our objective was to determine the incidence and severity of injuries from rentable e-scooters among adults presenting to EDs in a northern urban region.

Methods: Adults presenting to all Edmonton EDs with injuries related to rentable e-scooters during 3 summers (2019-2021) were eligible for inclusion. We identified e-scooter charts using multiple sources: administrative data, trauma registry, and text-based triage searching. Two independent reviewers assessed each patient for study inclusion; disagreements were resolved by content experts. Trained researchers performed data extraction and descriptive statistical analysis.

Results: We included 759 e-scooter-related injury presentations. The median age was 28 years, males and females were almost equally represented, 20% presented by ambulance, and 14% were triaged as urgent. Most patients had multiple injuries (62%), with fractures (32%) and head injuries (17%) being common. Helmet use was infrequent (2%) and concurrent substance use was prevalent (26%). Admission to hospital was uncommon (5.5%); however, 30% of patients presenting to an ED with an e-scooter injury required further follow-up, with 9% undergoing surgery within 30 days of their index visit.

Conclusion: Injuries related to rentable e-scooters are increasingly common. Most injured patients have multiple injuries and require investigations, and a third require further management. These injuries represent substantial burdens to patients and the health care system in Canada. Injury prevention strategies should be considered to reduce injuries.

Background: Gender diversity is lacking in the orthopedic workforce, and patient outcomes are known to be negatively affected when gender inequity exists. Following an unpublished needs assessment, we sought to evaluate participants' proposed solutions to gender inequity faced by female orthopedic surgeons in Canada and to translate the range of solutions into a medical education model.

Methods: Open-text responses from a gender-bias survey of Canadian orthopedic surgeons who identified as women were analyzed qualitatively by 2 experts. The questions covered the domain of changes required to improve the work environment. We used the latter 2 steps of Kern's educational framework as a lens to interpret the data and generate solutions.

Results: A total of 330 eligible surgeons were approached, and 220 (67.0%) completed the survey. Respondents provided more than 14 000 words of text for analysis. Using the themes of the unpublished needs assessment, we defined broad goals and specific objectives, including raising awareness, establishing an equitable playing field, drawing attention to male privilege, developing effective mentorship, eliminating harassment, and unburdening the second shift. We present solutions via educational strategies and evaluative methods based on Kern's framework.

Conclusion: We offer a road map for improving gender diversity in orthopedic surgery, based on survey results from Canadian women in orthopedic surgery, analyzed using a gender bias framework and an educational conceptual framework. We hope that this work will improve the surgical profession and patient care.

Background: High rates of hospital revisits after pediatric appendectomy are costly to the health care system, patients, and families. We sought to trial a bundle of interventions targeted at reducing the rate of unnecessary revisits to hospital in this population.

Methods: In February 2021, a working group of relevant stakeholders was created. In June 2021, the group developed and implemented interventions to reduce revisits in a staggered fashion. Interventions included increased education provided to patients and their families, as well as nursing staff, revised discharge pamphlets, and a post-discharge phone call from our nurse practitioner. We tracked revisit rates prospectively using run charts with comparison to historical controls.

Results: We tracked revisit rates from July 2018 to October 2022. A total of 793 appendectomies were performed. There was a downward trend in revisit rates, from 16.7% before interventions to 13.4% after intervention implementation, for a relative reduction of 20%. In the postintervention period, 193 appendectomies were performed, with 78.0% contacted by our nurse practitioner in the early postoperative period. Of those contacted, 74% received the discharge pamphlet and 98.7% of respondents expressed that the phone call was useful. Almost all respondents stated they would want the follow-up phone call if they were to have another child with appendicitis.

Conclusion: Simple, low-cost interventions aimed at improving education at time of discharge after pediatric appendectomy were associated with a reduction in unnecessary hospital revisits. Ongoing efforts are required to sustain results and assess efficacy of bundle elements to determine if additional initiatives may be beneficial in further reductions of revisits.

SummaryThe Canadian Undergraduate Surgical Education Committee (CUSEC) undertook a project to address variance in undergraduate surgical learning objectives among Canada's medical schools. Its aim was to compile a reasonable set of national undergraduate surgical learning objectives (NUSLOs) for all medical undergraduates and map them to the Medical Council of Canada (MCC) objectives. In phase 1, CUSEC invited Canada's 10 surgical specialty societies or associations to identify discipline-specific lists of undergraduate surgical learning objectives deemed essential for all Canada's medical students to achieve by the time of graduation. In phase 2, 8 medical students and 7 CUSEC faculty from 6 Canadian universities mapped each individual NUSLO to the corresponding MCC objectives, then to primary and secondary MCC objectives. By 2023, all 10 surgical specialty societies had derived, ratified, and submitted their discipline-specific NUSLOs, for a total of 72 major objectives, some of which had sub-objectives. All phase 1 NUSLOs were mapped to corresponding MCC objectives, with each NUSLO mapping to an average of 18 MCC objectives. Each NUSLO was then tiered to 1-2 primary MCC objectives. The NUSLOs and the NUSLO-MCC maps, now publicly posted on the CUSEC website, may serve as a foundational reference for students and teachers. They are a means by which Canada's medical schools can customize, standardize, and revise their undergraduate surgical curricula.