Ursodeoxycholic acid for prevention of gallstone disease after laparoscopic sleeve gastrectomy: an Atlantic Canada perspective.

BACKGROUND: Prophylactic ursodeoxycholic acid (UDCA) may be beneficial in reducing gallstone disease after bariatric surgery. The American Society for Metabolic and Bariatric Surgery (ASMBS) 2019 guidelines recommend a 6-month course of UDCA for patients undergoing laparoscopic sleeve gastrectomy (LSG). This has not been adopted broadly. This study intends to assess the effect of routine UDCA administration following LSG on symptomatic gallstone disease. METHODS: We performed a retrospective chart review of patients who underwent LSG, between 2009 and 2019, at two tertiary care centers in Atlantic Canada. At one center, UDCA 250 mg oral twice daily was routinely prescribed following LSG for 6 months to patients with an intact gallbladder. At the other center, UDCA was not prescribed. Primary and secondary outcomes were cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) rates. Compliance with and side effects of UDCA therapy were analyzed. RESULTS: A total of 751 patients were included in the study. Patients who had prior cholecystectomy or were lost to follow up were excluded. After exclusion criteria were applied, 461 patients were included for analysis: 303 in the UDCA group and 158 in the group who did not receive UDCA. Cholecystectomy rate was not significantly associated with UDCA administration, however there was a trend towards less cholecystectomy in patients who received UDCA (8.3% vs. 13.9%, p = 0.056). ERCP rate was significantly lower in patients who received UDCA (0.3% vs 2.5%, p = 0.031). Rate of gallstone disease requiring intervention, either cholecystectomy or ERCP, was significantly decreased in patients who received UDCA (8.9% vs 15.8%, p = 0.022). The most common barriers to compliance with UDCA were cost (45.4%) and nausea (18.1%). CONCLUSION: This is the first study to demonstrate lower rates of ERCP in patients receiving routine UDCA following LSG. Our findings support the ASMBS 2019 guidelines for administering UDCA after LSG for preventing gallstone disease.

An estimation of the endoscopist's musculoskeletal injury risk for right and left lateral decubitus positions during colonoscopy: a field-based ergonomic study.

BACKGROUND: Colonoscopy exposes endoscopists to awkward postures and prolonged forces, which increases their risk of musculoskeletal injury. Patient positioning has a significant impact on the ergonomics of colonoscopy. Recent trials have found the right lateral decubitus position is associated with quicker insertion, higher adenoma detection rates, and greater patient comfort compared to the left lateral decubitus position. However, this patient position is perceived as more strenuous by endoscopists. METHODS: Nineteen endoscopists were observed performing colonoscopies during a series of four-hour endoscopy clinics. Durations of each patient position (right lateral decubitus, left lateral decubitus, prone, and supine) were recorded for all observed procedures (n = 64). Endoscopist injury risk was estimated by a trained researcher for the first and last colonoscopies of the shifts (n = 34) using Rapid Upper Limb Assessment (RULA), an observational ergonomic tool that estimates risk of musculoskeletal injury by scoring postures of the upper body and factors such as muscle use, force, and load. The total RULA scores were compared with a Wilcoxon Signed-Rank test for patient position (right and left lateral decubitus) and time (first and last procedures) with significance taken at p < 0.05. Endoscopist preferences were also surveyed. RESULTS: The right lateral decubitus position was associated with significantly higher RULA scores than the left lateral decubitus position (median 5 vs. 3, p < 0.001). RULA scores were not significantly different between the first and last procedures of the shifts (median 5 vs. 5, p = 0.816). 89% of endoscopists preferred the left lateral decubitus position, primarily due to superior ergonomics and comfort. CONCLUSION: RULA scores indicate an increased risk of musculoskeletal injury in both patient positions, with greater risk in the right lateral decubitus position.

Ambulatory surgery centres: a potential solution to a chronic problem.

SummaryLong wait times for elective surgery in Canada have been a persistent problem for many years and the recent pandemic has made the situation substantially worse. Current evidence suggests that ambulatory surgery centres are more cost-effective and efficient in the delivery of ambulatory surgical services than larger institutions. We explore the merits of a network of publicly funded ambulatory surgery centres.

Challenges and opportunities in providing high-quality surgical care in Canada.

SummaryThe provision of surgical care in Canada requires substantial improvement. In this commentary, we use the US Institute of Medicine's framework for assessing the quality of health care to explore system-wide challenges that affect surgical outcomes in Canada. Challenges include surgical wait times, long travel times for surgery, human resource constraints, equitable access to surgery, limited collection of data about the surgical pathway, a lack of transparency in the reporting of surgical outcomes and a lack of incentives for hospital systems to achieve high-quality outcomes. We propose solutions supported by available literature to help overcome some of these challenges.

Management of the colonic polyps referred for surgery: an opportunity for improvement.

PURPOSE: To examine local practice for non-malignant polyps and to calculate morbidity and mortality associated with bowel resection for this indication. METHODS: This retrospective cohort study was conducted by reviewing our local gastrointestinal pathology database over a five-year period to identify colonic resections performed for benign polyps. Using search terms "polyp" and "adenoma," 272 cases were identified. Exclusion criteria included: cancer diagnosis, emergency surgeries, multiple resections, and subtotal colectomies for polyposis. 106 patients were included in the study. Primary outcome was perioperative mortality. Secondary outcomes included patient morbidity, characteristics of polyps requiring surgery, and the number of patients referred for a second endoscopic opinion prior to proceeding with surgery. RESULTS: 64 male and 42 female patients with a mean age of 65.3 years (± 8.6 years) underwent colon resection for benign polyps. The mean polyp size was 32.7 mm (± 19.5 mm). 30 patients (28.6%) had polyps equal to or less than 2 cm. Most of the polyps described were sessile (n = 55, 51.9%) and located in the right colon (n = 84, 79.3%). Endoscopic resection was attempted in 31 patients (29.2%), and five cases (4.7%) were referred for a second endoscopic opinion prior to proceeding with surgery. Endoscopists incorrectly felt that polyps were malignant in 62 cases (58.5%). Using Clavien-Dindo classification, most patients had no complications n = 36 (34.0%) or minor complications n = 41 (38.7%). Twelve patients (11.3%) had complications that required antibiotics, blood transfusions, or total parental nutrition. Nine patients (8.5%) required surgical or endoscopic management. Six patients (5.7%) required ICU admission. Mortality rate was 1.9% (n = 2). CONCLUSION: Surgery for benign colonic polyps is associated with significant morbidity and mortality. These findings reveal a gap in endoscopic management of benign colonic polyps.

Optimizing cecal views during colonoscopy using patient position change.

BACKGROUND: Patient positioning has been found to be a simple technique to improve luminal distention and visualization during colonoscopy. This study examined which position provided the cleanest image of the cecum using the Boston Bowel Prep Scale (BBPS) and the best view of the cecum overall as ranked by blinded assessors. METHODS: A sample of 90 sets of cecal images were obtained from patients undergoing a non-urgent colonoscopy. Each set included cecal images of patients while lying in three positions-right lateral decubitus, left lateral decubitus, and supine. Two authors reviewed these sets of images and excluded those that were unclear. A third author, blinded to the position, selected the final 33 sets of images. Two experienced endoscopists completed a blinded survey of each image set. They used the BBPS to assess and score each image as the primary outcome measure. The endoscopists also ranked each image set in terms of the best overall view of the cecum. Data were collected using Qualtrics software. Nonparametric tests were used to analyze the data using SPSS software (v.25). A p-value of ≤ 0.05 was considered significant. RESULTS: The BBPS showed a significant difference between patient positions when tested by Kruskal-Wallis. Subsequent Mann Whitney U tests indicated that the right lateral decubitus position was ranked higher than left lateral decubitus or supine positions. There was no significant difference in the left and supine positions. Cohen's Kappa suggested moderate agreement between raters. The raters also favored the right lateral position over the other positions when assessing overall image preference displaying the cecum. CONCLUSION: These results indicate that positioning patients in the right lateral decubitus position provides the best view of the cecum during colonoscopy.

Paediatric enteric fever in Brussels: a case series over 16 years.

Enteric fever (EF) is a major public health problem and a witness of the global health disparities. It is caused by Salmonella enterica serovar Typhi (Salmonella ser. Typhi) and Salmonella enterica serovar Paratyphi A, B, C (Salmonella ser. Paratyphi) and is estimated to infect 12-26 million persons yearly. Paediatric data on enteric fever in Europe are scarce. A case series of EF was analysed to describe the clinical presentation, laboratory characteristics and diagnostic challenges identified in a paediatric population in Brussels. We performed a retrospective study of all lab-confirmed cases of enteric fever in children aged 0-15 years at two Brussels teaching hospitals, between January 2005 and December 2020. We reviewed age, gender, travel history, consultations before diagnosis, hospitalisation duration, clinical symptoms and laboratory findings. There were 34 positive isolates of S. typhi and S. paratyphi: 31 patients had positive blood culture, 1 patient had positive bone aspirate and 2 patients had positive stool culture (one was excluded for missing data). There were 20 girls (60%). Median age was 3.5 years (range 5 months to 14 years). Travel to EF endemic areas was present in 55% of patients. Diagnosis was delayed in 80% of children. Eosinopenia was present in 93% of the cohort. The patients had not received any preventive travel education or vaccination.  Conlusion: Enteric fever poses diagnostic challenges to clinicians. Eosinopenia in a febrile patient coming from the tropics should raise suspicion of EF. Travellers to endemic areas should be better educated about EF risks, and typhoid fever vaccination must be promoted. What is Known: • Enteric fever is a global public health problem and includes typhoid and paratyphoid fever. • Typhoid fever is vaccine preventable disease. Paratyphoid fever is not vaccine preventable. What is New: • Enteric fever diagnosis is very challenging in non-endemic settings, and a large proportion of patients may develop serious complications if they receive delayed management. Occurrence of small family clusters is possible and mandates education and monitoring of the families of enteric fever affected children. • We report that the widest majority of our enteric fever affected patients (69%) had aneosinophilia (zero eosinophil count), and almost all patients (93%) had eosinopaenia (less than 50 eosinophil count) during their bacteriaemic phase.

Research and surgical residency: moving beyond one-and-done projects and motivating for scholarly excellence.

Among surgical residents, research is often perceived as a check-mark exercise. Focus then turns to studying for exams and honing skills for independent practice. While some residents are passionate about research and enroll in other formalized training, pragmatists argue that not every surgeon should engage in research at this level. However, no resident should view research as a one-and-done activity. Rather, research should be viewed as an exercise to improve practice, share gaps in knowledge, collaborate, and empower others to formally study and implement change. The skills acquired during research experiences, at minimum, have value in improving the trainee's literature literacy, which in turn serves as a foundational element of continuing medical education. A culture supportive of scientific discovery, facilitated by both faculty and peer-to-peer mentorship, will result in better collaborative efforts and lead to improved knowledge generation and resident research satisfaction.

A framework for role allocation in education, research and leadership services in Canadian academic divisions of general surgery: a modified Delphi consensus.

BACKGROUND: Moving toward a funding standard similar to that for clinical services for roles essential to the functioning of education, research and leadership services within divisions of general surgery is necessary to strengthen divisional resilience. We aimed to identify roles and underlying tasks in these services central to sustainable functioning of Canadian academic divisions of general surgery. METHODS: Between June 2018 and October 2020, we used a 4-step modified Delphi method (online survey, face-to-face nominal group technique [n = 12], semistructured telephone interview [n = 8] and nominal group technique [n = 12]) to achieve national consensus from an expert panel of all 17 heads of academic divisions of general surgery in Canada on the roles and accompanying tasks essential to education, research and leadership services within an academic division of general surgery. We used 70% agreement to determine consensus. RESULTS: The expert panel agreed that a framework for role allocation in education, research and leadership services was relevant and necessary. Consensus was reached for 7 roles within the educational service, 3 roles within the research service and 5 roles within the leadership service. CONCLUSION: Our framework represents a national consensus that defines role standards for education, research and leadership services in Canadian academic divisions of general surgery. The framework can help divisions build resiliency, and enable sustained and deliberate advances in these services.

Is ethnicity an appropriate measure of health care marginalization? A systematic review and meta-analysis of the outcomes of diabetic foot ulceration in Aboriginal populations.

BACKGROUND: Aboriginal people have higher prevalence rates of diabetes than non-Aboriginal people in the same geographic locations, and diabetic foot ulcer (DFU) complication rates are also presumed to be higher. The aim of this systematic review and meta-analysis was to compare DFU outcomes in Aboriginal and non-Aboriginal populations. METHODS: We searched PubMed, Embase, CINAHL and the Cochrane Library from inception to October 2018. Inclusion criteria were all types of studies comparing the outcomes of Aboriginal and non-Aboriginal patients with DFU, and studies from Canada, the United States, Australia and New Zealand. Exclusion criteria were patient age younger than 18 years, and studies in any language other than English. The primary outcome was the major amputation rate. We assessed the risk of bias using the ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) tool. Effect measures were reported as odds ratio (OR) with 95% confidence interval (CI). RESULTS: Six cohort studies with a total of 244 792 patients (2609 Aboriginal, 242 183 non-Aboriginal) with DFUs were included. The Aboriginal population was found to have a higher rate of major amputation than the non-Aboriginal population (OR 1.85, 95% CI 1.04-3.31). Four studies were deemed to have moderate risk of bias, and 2 were deemed to have serious risk of bias. CONCLUSION: Our analysis of the available studies supports the conclusion that DFU outcomes, particularly the major amputation rate, are worse in Aboriginal populations than in non-Aboriginal populations in the same geographic locations. Rurality was not uniformly accounted for in all included studies, which may affect how these outcome differences are interpreted. The effect of rurality may be closely intertwined with ethnicity, resulting in worse outcomes.

The impact of COVID-19 on surgical education: perspectives from Canadian general surgery residents.

Most institutions have mitigated the impact of the COVID-19 pandemic on residency education by transitioning to web-based educational platforms and using innovative solutions, such as surgical video libraries, telehealth clinics, online question banks via social media platforms, and procedural simulations. Here, we assess the perceived impact of COVID-19 on Canadian surgical residency education and discuss the unique challenges in adapting to a virtual format and how novel training methods implemented during the pandemic may be useful in the future of surgical education.

The epidemiology of invasive meningococcal disease and the utility of vaccination in Malta.

Invasive meningococcal disease (IMD) is a vaccine-preventable devastating infection that mainly affects infants, children and adolescents. We describe the population epidemiology of IMD in Malta in order to assess the potential utility of a meningococcal vaccination programme. All cases of microbiologically confirmed IMD in the Maltese population from 2000 to 2017 were analysed to quantify the overall and capsular-specific disease burden. Mean overall crude and age-specific meningococcal incidence rates were calculated to identify the target age groups that would benefit from vaccination. Over the 18-year study period, 111 out of the 245 eligible notified cases were confirmed microbiologically of which 70.3% had septicaemia, 21.6% had meningitis, and 6.3% had both. The mean overall crude incidence rate was 1.49/100,000 population with an overall case fatality rate of 12.6%. Meningococcal capsular groups (Men) B followed by C were the most prevalent with W and Y appearing over the last 6 years. Infants had the highest meningococcal incidence rate of 18.9/100,000 followed by 6.1/100,000 in 1-5 year olds and 3.6/100,000 in 11-15 year old adolescents. The introduction of MenACWY and MenB vaccines on the national immunization schedule in Malta would be expected to reduce the disease burden of meningococcal disease in children and adolescents in Malta.

A randomized controlled trial comparing right and left lateral decubitus starting position on outcomes in colonoscopy.

BACKGROUND: Patient positioning in colonoscopy has been proposed as a simple and inexpensive technique to increase luminal distention and improve navigation through the large bowel. We sought to determine if the right lateral (RL) starting position compared to the standard left lateral (LL) starting position could improve outcomes in colonoscopy. METHODS: We conducted a randomized controlled trial of 185 patients who were undergoing an elective colonoscopy. Patients were randomized to either a right lateral decubitus starting position or a left lateral decubitus starting position and the primary outcome measure was cecal intubation time. Secondary outcome measures included cecal intubation rate, patient discomfort, and sedation dosage. All colonoscopists who had successfully completed a colonoscopy skills improvement course were included in the trial. A sample size was calculated prior to the start of the study and outcomes were analyzed using univariate and multiple regression analyses. RESULTS: A total of 94 patients were randomized to RL starting position and 91 patients were randomized to LL starting position. No difference was found in time to cecal intubation comparing the RL starting position (542.6 s, SD 360.7 s) to LL starting position (497.85 s, SD 288.3 s) (p = 0.354). Variables associated with prolonged cecal intubation time included female gender, General Surgery specialty, less than 5 years of endoscopist experience, a high patient discomfort score, amount of water used, and number of position changes required to reach the cecum. There was no difference in any of the secondary outcome measures aside from the amount of midazolam used, with more midazolam used for patients starting in the right lateral decubitus position. CONCLUSION: This study failed to show an association between cecal intubation time and patient position comparing right and left lateral starting position.

Effect of an educational intervention on colonoscopy quality outcomes.

BACKGROUND: We aimed to assess the effect of a colonoscopy skills improvement (CSI) course on quality indicators at our institution. METHODS: This retrospective cohort study included ten surgeons and nine gastroenterologists practicing in a tertiary referral center who had undergone CSI training between 2014 and 2015. Procedural data for 50 colonoscopies by each physician was collected immediately before and after CSI training, and again 8 months after training. The primary outcome was adenoma detection rate (ADR) and secondary outcomes included colonoscopy completion rate (CCR), and withdrawal time (WT). Univariate analysis followed by stepwise multivariable logistic regression was performed to assess for predictors of these outcomes. These variables included patient age, gender, indication for colonoscopy, quality of bowel preparation, and CSI training. RESULTS: 2533 colonoscopies were included. There was no improvement in ADR for the entire group immediately after training and at 8 months (31.8% vs. 33.6% vs. 35.3%, p = 0.319). In subgroup analysis, the ADR of surgeons improved non-significantly immediately after completing the course and increased further at 8 months (30.9% vs. 31.6% vs. 37.6%, p = 0.065). The same changes were not observed for the gastroenterology subgroup (32.9% vs. 36.0% vs. 32.8%, p = 0.550). No change was noted in CCR or WT. In multivariate analysis of the surgical subgroup, increased patient age, male gender, and the 8-month time point following CSI training were associated with higher ADR. CONCLUSION: CSI training is associated with an improvement in ADR for surgeons at our institution.

Blunt Trauma: What Is Behind the Widened Mediastinum on Chest X-Ray (CXR)?

BACKGROUND: It is commonly taught that a widened mediastinum (WM) on chest X-ray (CXR) is a marker for aortic injury (AI). We sought to describe the epidemiology of injuries for all patients with WM and compare their CXR to those of patients with confirmed AI. METHODS: Adults (age ≥ 18) sustaining blunt traumatic injuries from January 2017 to June 2017 with both CXR (supine, anterior-posterior) and chest CT were included. We excluded those whose CT preceded CXR and those with missing data. Basic demographics, injury characteristics, mediastinal width (MW), mediastinal-to-thoracic width ratio (MTR), and all thoracic imaging findings were analyzed. MW > 8 cm was considered WM. We also queried our registry for all AI patients over a 4-year period. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of WM on CXR for AI were calculated. Multivariate logistic regression was performed to identify factors associated with positive traumatic findings, controlling for body mass index (BMI), sex, high-energy mechanism, MTR, and mediastinal width. RESULTS: Of 749 included subjects, 502 (67%) had an MW > 8 cm: mean age was 48 ± 20 y, 381 (76%) were men, and BMI was 28 ± 5 kg/m2. Mechanism of injury was motor vehicle crash in 335 (67%); fall in 113 (23%); assault in 31 (6%); other (jet-ski accidents, etc.) in 17 (3%), and unknown in 6 (1%). Only 128 (26%) of patients with WM had positive findings on CT, with the most common [80 (16%)] being nontraumatic findings (pericardial infusion, lymph nodes, etc.), followed by hemomediastinum/pneumomediastinum [32 (6%)], sternal fractures [18 (4%)], multiple findings [15 (3%)], and vertebral fractures [6 (1%)]. Only 2 (1%) had AI. The sensitivity was 100%, specificity was 33%, PPV was 0.4%, NPV was 100%, and accuracy was 33%. From 2013 to 2017, 38 patients had AI: mean age was 46 ± 19 y, 26 (68%) were men, and BMI was 28 ± 4 kg/m2. Motor vehicle crash was the most common mechanism (89%), followed by "other" trauma mechanism (5%), fall (3%), and assault (3%). On univariate analysis, compared with all patients with WM, patients with AI had significantly greater MW (9.5 [8.8-10.4] versus 10.2 [9.1-11.1]; P = 0.042) and MTR (0.31 [0.28-0.34] versus 0.32 [0.31-0.37]; P = 0.001), although the actual differences were not clinically significant. The regression analysis did not identify any factors associated with traumatic CXR findings. CONCLUSIONS: Most bluntly injured adults have a WM, and the majority have either no findings or nontraumatic findings. The PPV of a WM for AI is <1%. WM on supine CXR is nonspecific and inaccurate for diagnosing traumatic injuries, especially AI.

NSAID administration post colorectal surgery increases anastomotic leak rate: systematic review/meta-analysis.

BACKGROUND: Current enhanced recovery guidelines suggest that opioid sparing medications should be used for analgesia whenever possible following colorectal surgery. The present study aims to assess whether post-operative NSAID use is associated with an increased anastomotic leak rate after a colonic or rectal anastomosis. METHODS: A systematic review was performed for studies investigating anastomotic leak rate following NSAID use vs control after colonic or rectal anastomosis. Meta-analysis was performed to assess for overall risk of anastomotic leak with NSAID use, as well as sub-group analysis to compare selective vs non-selective NSAIDs and drug-specific NSAID safety profiles. RESULTS: Seven studies were included in the final review. Use of an NSAID post-operatively was associated with an overall increased risk of anastomotic leakage [OR 1.58 (1.23, 2.03), P = 0.0003]. Non-selective NSAIDs were associated with an increased risk [OR 1.79 (1.47, 2.18), P < 0.00001], but selective NSAIDs were not. The non-selective NSAID diclofenac was associated with an increased leak rate [OR 2.79 (1.96, 3.96), P < 0.00001], but ketorolac was not [OR 1.36 (0.89, 2.06), P = 0.16]. CONCLUSIONS: Great caution must be taken when prescribing NSAIDs following colonic or rectal anastomotic creation. The safety profile varies within the NSAID class and further research is needed to clarify which NSAIDs are safe for use and which are not.

Annual colonoscopy volume and maintenance of competency for surgeons.

INTRODUCTION: To determine whether the annual case volume of general surgeons (greater or less than 200 colonoscopies) is associated with quality outcomes. METHODS: This retrospective cohort study involved all adults who underwent colonoscopy by a surgeon in the city of St. John's, NL, during the first 6 months of 2012. Subjects were identified through records from the health authority, and data were recorded on a standardized data sheet. Univariate analysis followed by stepwise multivariable logistic regression was performed to determine whether there was an association between quality outcomes (colonoscopy completion rate, adenoma detection rate) and predictors of these outcomes including annual colonoscopy volume, patient age, gender, indication for colonoscopy, and ASA score. A Chi-squared test was used to determine whether other outcomes were associated with annual colonoscopy volume. RESULTS: Data were collected on 1060 patients. Mean age was 59.5 (sd 12.2) years with 550 females. A total of 13 surgeons were studied, of which 7 performed less than 200 annual colonoscopies over the previous 2 years (low-volume group) and 6 performed more than 200 annual colonoscopies over the previous 2 years (high-volume group). While there was a significant difference in the colonoscopy completion rate favoring the high-volume group (82.2 vs. 91.1 %, p < 0.001), no difference was noted in the adenoma detection rate between groups (16.7 vs. 17.7 %, p = 0.762). The regression model revealed that colonoscopy completion was also associated with an indication of screening or surveillance and an ASA score of 1 or 2. The adenoma detection rate was associated with older age and male gender. There was no statistically significant association between annual colonoscopy volume and other safety outcome measures. CONCLUSION: Performing over 200 colonoscopies annually is associated with higher colonoscopy completion rates, but does not appear to be associated with other quality measures.

The usefulness and costs of routine contrast studies after laparoscopic sleeve gastrectomy for detecting staple line leaks.

BACKGROUND: Although laparoscopic sleeve gastrectomy (LSG) has been shown to be a safe and effective treatment for severe obesity (body mass index ≥ 35), staple line leaks remain a major complication and account for a substantial portion of the procedure's morbidity and mortality. Many centres performing LSG routinely obtain contrast studies on postoperative day 1 for early detection of staple line leaks. We examined the usefulness of Gastrografin swallow as an early detection test for staple line leaks on postoperative day 1 after LSG as well as the associated costs. METHODS: We conducted a retrospective review of a prospectively collected database that included 200 patients who underwent LSG for severe obesity between 2011 and 2014. Primary outcome measures were the incidence of staple line leaks and the results of Gastrografin swallow tests. We obtained imaging costs from appropriate hospital departments. RESULTS: Gastrografin swallow was obtained on postoperative day 1 for all 200 patients who underwent LSG. Three patients (1.5%) were found to have staple line leaks. Gastrograffin swallows yielded 1 true positive result and 2 false negatives. The false negatives were subsequently diagnosed on computed tomography (CT) scan. The sensitivity of Gastrografin swallow in this study was 33%. For 200 patients, the total direct cost of the Gastrografin swallows was $35 000. CONCLUSION: The use of routine upper gastrointestinal contrast studies for early detection of staple line leaks has low sensitivity and is costly. We recommend selective use of CT instead.

CONTEXTE: Même si la gastrectomie longitudinale par laparoscopie (GLL) s'est révélée sûre et efficace pour le traitement de l'obésité sévère (indice de masse corporelle ≥ 35), les fuites survenant à la ligne d'agrafes demeurent une complication majeure et sont responsables d'une bonne partie des complications et des décès associés à cette chirurgie. Plusieurs des centres effectuant des GLL procèdent au dépistage systématique des fuites à la ligne d'agrafes en réalisant des tests avec des agents de contraste le jour suivant la chirurgie. Nous avons évalué l'utilité du test à la gastrografine comme méthode de dépistage précoce des fuites à la ligne d'agrafes au jour 1, ainsi que les coûts qui y sont associés. MÉTHODES: Nous avons mené une étude rétrospective à partir d'une base de données créée de façon prospective qui portait sur 200 patients ayant subi une GLL entre 2011 et 2014 en raison d'une obésité sévère. Les principaux indicateurs de résultats étaient l'incidence de fuites à la ligne d'agrafes et les résultats obtenus aux tests à la gastrografine. Les renseignements sur le coût des tests d'imagerie nous ont été fournis par les départements appropriés des hôpitaux. RÉSULTATS: Selon les résultats des tests à la gastrografine au jour 1 obtenus pour les 200 patients ayant subi une GLL, 3 patients (1,5 %) présentaient des fuites à la ligne d'agrafes. Il s'agissait en réalité d'un vrai positif et 2 faux négatifs. Le diagnostic des faux négatifs a ensuite été effectué par tomographie par ordinateur. La sensibilité du test à la gastrografine était donc de 33 % au cours de cette étude. Le coût total de ce test, pour les 200 patients, était de 35 000 $. CONCLUSION: Le recours à des examens systématiques du tractus gastro-intestinal supérieur au moyen d'agents de contraste pour le dépistage précoce des fuites à la ligne d'agrafes a une faible sensibilité et est associé à des coûts élevés. Nous recommandons plutôt l'utilisation sélective de la tomographie par ordinateur.

Does the hands-on, technical training of residents in colonoscopy affect quality outcomes?

INTRODUCTION: The training of residents in colonoscopy has become an important topic as more attention is being paid to quality outcomes. PURPOSE: To determine whether colonoscopy quality outcomes are adversely affected by allowing residents to perform colonoscopies under supervision. METHODS: This retrospective cohort study was performed on all adults who underwent colonoscopy in the city of St. John's, NL, from January to June 2012 by an endoscopist who trains residents. Subjects were identified through records from the health authority. Data were extracted from the electronic medical record, including the endoscopy procedure report, the nursing record of the endoscopy, and the pathology report. Data were recorded on a standardized data sheet and entered into SPSS version 19.0 for analysis. A Chi-squared test was used for categorical data and a t test was used for continuous data. RESULTS: A total of 867 cases involving seven endoscopists and three trainees were studied. The colonoscopy was performed by an endoscopist in 673 cases and performed by a trainee in 194 cases. Mean age [59.3 (SD 12.44) years] and gender (51.7% female) were similar between groups. There was no difference in cecal intubation rate (90.6 vs. 89.2%, p = 0.544) between endoscopists and trainees. There was a difference in polyp detection (23.3 vs. 33.5%, p = 0.004) and adenoma detection (12.8 vs. 22.7%, p = 0.034) favoring the trainees. There was no difference in the average dose of Fentanyl given (98.4 vs. 94.9 mg, p = 0.066), but there was less use of Versed favoring the trainee group (3.59 vs. 3.31 mg, p = 0.002). There was no difference in the endoscopy nurses' perception of patient discomfort between groups (28.7 vs. 26.7%, p = 0.632). CONCLUSION: The presence of a trainee does not appear to adversely affect quality outcomes in colonoscopy. When the polyp and adenoma detection rates of endoscopists are low, the addition of a trainee may improve these detection rates.