Canadian Journal of Surgery最新文献

Background: Timing to surgery for acute cholecystitis remains variable, ranging from early (< 7 d) to delayed surgery (> 7 d). Accelerated surgery may result in better outcomes owing to reduced exposure to hypercoagulable and inflammatory states. We sought to determine the feasibility of a trial comparing accelerated surgery with standard care among patients with calculous acute cholecystitis.

Methods: We conducted a multicentre pilot randomized controlled trial. We randomly assigned adult patients with acute cholecystitis to receive accelerated surgery (i.e., goal of surgery within 6 hours of diagnosis) or standard care. The primary feasibility outcome included recruitment of 60 patients, randomly assigning the equivalent of 1 patient per site per month, and 95% follow-up at 90 days.

Results: Sixty patients (mean age 61.7, standard deviation [SD] 13.5, yr; 27 [45%] female) were randomly assigned to accelerated surgery (n = 31) or standard care (n = 29) from December 2019 to December 2021, with 2 recruitment pauses due to the COVID-19 pandemic. The median time from diagnosis to surgery was 5.8 (interquartile range [IQR] 4.4-11.1) hours in the accelerated care arm and 20.3 (IQR 6.8-26.8) hours in the standard care arm. Across 4 sites, 4.6 patients per month were randomly assigned. All patients completed the 90-day follow up.

Conclusion: In our pilot trial, we found that accelerated cholecystectomy was achievable. These results show the feasibility of a trial comparing accelerated and standard care among patients requiring surgery for acute cholecystitis and support a definitive trial.

Trial registration: ClinicalTrials.gov, no. NCT04033822.

Background: Trauma educational opportunities for general surgery residents in Canada are uncharacterized. We aimed to characterize these opportunities for and identify factors associated with such opportunities.

Methods: We performed a prospective cross-sectional study characterizing trauma educational opportunities within Canadian trauma programs. Data were collected during 1 summer week and 1 winter week. We summarized educational opportunities by trauma site and season and used multivariable modelling to evaluate factors associated with increased likelihood of procedure opportunities.

Results: Nine academic trauma centres participated. Most consults (93.9%) and trauma team activations (TTAs) (72.3%) were for blunt injuries, and most presentations were during the summer (67.2% TTAs + consults, 69.3% TTAs). Trauma services cared for a median of 14 (interquartile range [IQR] 10-20) inpatients, 4 (IQR 1-6) patients in the intensive care unit, and 0 (IQR 0-2) patients admitted to another service but subsequently followed by a trauma physician (i.e., consulting patients), which varied across hospitals (p < 0.001). Consult, TTA, nonoperative, and operative procedure volumes varied across sites. The most common operative procedures were laparotomies (36.4%), with 1.33 laparotomies per week per site. For nonlaparotomy operations, the maximum volume was 6 over 2 weeks. More operations occurred during summer (74.2%) than winter. Multivariable modelling determined that penetrating mechanisms (odds ratio [OR] 1.87, 95% confidence interval [CI] 1.11-3.15) and TTAs with a trauma surgeon present (OR 2.37, 95% CI 1.59-3.54) were associated with increased likelihood of procedures.

Conclusion: Trauma educational opportunities remain heterogeneous across Canada. Higher volumes of patients with trauma were seen during the summer. Penetrating mechanism and TTAs with a trauma surgeon present appear to increase opportunities to perform procedures. Our results can inform general surgery training programs to optimize resident trauma training in Canada.

Background: Strategies to address inequities, bias, and discrimination that disadvantage Canadian physicians from marginalized groups are urgently needed. We describe a multilevel needs assessment of equity, diversity, and inclusion (EDI) in 2 departments of surgery that focused on identifying evidence-based interventions.

Methods: We invited members of the departments of surgery at the University of Calgary and the University of Saskatchewan to complete the Diversity Engagement Survey (DES), a 22-item instrument designed to understand workplace engagement and inclusion among physicians, with higher scores indicating greater engagement and inclusion. Leaders completed a Leadership EDI Readiness Assessment to understand their own barriers to EDI work and an Organizational EDI Readiness Assessment to understand structures for EDI in their division. Leaders were provided resources and interventions to address the identified gaps in these assessments.

Results: The most common organizational gaps in structures for EDI work in surgical divisions and training programs (n = 34, 37.4%) were in community outreach and measurement and reporting. Surgeons who identified as cisgender men (n = 101) felt more engaged and included than those who identified as cisgender women (n = 43; 3.81 [standard deviation (SD) 0.73] v. 3.51 [SD 0.78]; p = 0.04). White cisgender men (n = 66) had the highest feelings of engagement and inclusion (mean 3.95 [SD 0.62]). Participating surgical sections and training programs were directed to evidence-informed initiatives to improve community outreach and measurement and reporting to address EDI in their settings.

Conclusion: Our findings support that gender and racial or ethnic identities influence the workplace experiences of surgeons in Canada. A multilevel approach to EDI work in surgical departments can direct leaders to areas for intervention.

SummaryWithin the field of global surgery, partnerships between low- and middle-income countries (LMICs) and high-income countries (HICs) are often used to improve surgical capacity and enhance surgical training. Similarly, medical rounds are common in postgraduate medical training, although joint rounds between LMICs and HICs have not been widely used. Over 1 year, 6 online joint education rounds were held for general surgery residents at the University of British Columbia and the University of Guyana. Rounds comprised resident-led case-based presentations on a surgical subspecialty topic. These rounds were evaluated by residents through an online survey and were found to be valuable and relevant to their training, with mutual and differential benefits to Canadian and Guyanese residents. This project demonstrated that joint rounds are a meaningful method to partner surgical residency programs and can provide another tool for implementation of global surgery.

Background: Ambulatory surgery centres are becoming an attractive alternative to hospital-based outpatient departments; however, limited data exist on their cost efficacy in a publicly funded health care model. In this study, we aimed to compare costs for ambulatory sports medicine procedures performed at an ambulatory surgery centre and a hospital outpatient department.

Methods: We retrospectively identified patients who underwent rotator cuff repair, anterior cruciate ligament reconstruction (ACLR), or hip arthroscopy between January 2020 and August 2022. We collected demographic characteristics, procedural costs, and procedural data. We used 2-sample t tests to compare care-related costs between groups treated in an ambulatory surgery centre and hospital outpatient department.

Results: After controlling for age and concomitant procedures, we included a total of 132 patients for analysis. Patients who underwent hip arthroscopy or rotator cuff repair in an ambulatory surgery centre had significantly shorter duration of total operating room time, and procedural duration was equivocal (p > 0.1) between sites. Procedure time for ACLR was significantly shorter in the group treated in an ambulatory surgery centre than in the group treated in a hospital outpatient department (p = 0.01). The total case costs for the ambulatory surgery centre were significantly lower for hip arthroscopy ($3543, standard deviation (SD) $365 v. $6209, SD $681; p < 0.05), rotator cuff repair ($4259, SD $934 v. $5786, SD $934; p < 0.05), and ACLR ($3136, SD $459 v. $4821, SD $1511; p < 0.05), despite a lack of differences in associated disposable implant costs for ACLR and rotator cuff repair (p > 0.1). Material costs were significantly lower in the group receiving hip arthroscopy at an ambulatory surgery centre than in the group receiving the same procedure at a hospital outpatient department (p < 0.05). There were no differences in immediate 6-week postoperative care-associated costs between groups (p > 0.4).

Conclusion: Ambulatory sports medicine procedures performed at an ambulatory surgery centre were associated with significantly reduced operating room time and total cost compared with matched cases performed via a hospital outpatient department. Ambulatory surgery centres provide an opportunity to improve cost efficacy and reduce wait-lists for surgical care.

Background: Transanal endoscopic microsurgery (TEM) is a safe and effective therapy for local excision of rectal lesions, but early postoperative infectious and inflammatory complications are variably defined in the literature. The aim of this study was to describe post-TEM syndrome, a cluster of postoperative symptoms related to a local inflammatory process seen in a subset of patients after TEM.

Methods: We conducted a retrospective cohort study using prospectively collected observational data of all patients who underwent TEM at St. Paul's Hospital in Vancouver, British Columbia, between 2006 and 2017.

Results: During the study period, 795 patients were treated by TEM at the study institution. Of these, 56 patients had postoperative pain or fever and 26 patients were determined to have post-TEM syndrome based on our definition. Sixteen patients presented within the first 2 postoperative days, with all patients presenting within 1 week. All patients who underwent cross-sectional imaging (n = 11) had a combination of inflammatory changes with stranding and free fluid, or with small bubbles of free intraperitoneal, retroperitoneal, or mesorectal air, or with both; they did not have signs of free perforation or abscess at the surgical site. Nearly all patients with post-TEM syndrome (96%) did not progress to further infectious complications. Most patients' (92%) post-TEM symptoms resolved within 1 week of conservative treatment.

Conclusion: We provided a description of post-TEM syndrome, the constellation of symptoms arising from a localized inflammatory response in a subset of patients after TEM. This syndrome is uncommon, and nearly all patients recovered with conservative management without a need for more invasive intervention.