Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review.

INTRODUCTION: Malignant bowel obstruction from peritoneal carcinomatosis affects a significant proportion of luminal gastrointestinal and ovarian oncology patients, and portends poor long-term survival. The management approach for these patients includes a range of medical therapies and surgical options; however, how to select an optimal treatment strategy remains enigmatic. The goal of this narrative review was to summarize the latest evidence around multimodal malignant bowel obstruction treatment and to establish if and where progress has been made. METHODS: A targeted literature search examining articles focused on the management of malignant bowel obstruction from peritoneal carcinomatosis was performed. Following data extraction, a narrative review approach was selected to describe evidence and guidelines for surgical prognostic factors, imaging, tube decompression, medical management, nutrition, and quality of life. RESULTS: Outcomes in the literature to date are summarized for various malignant bowel obstruction treatment strategies, including surgical and non-surgical approaches, as well as a discussion of the role of total parenteral nutrition and chemotherapy in holistic malignant bowel obstruction management. CONCLUSION: There has been little change in survival outcomes in malignant bowel obstruction in over more than a decade and there remains a paucity of high-level evidence to direct treatment decision making. Healthcare providers treating patients with malignant bowel obstruction should work to establish consensus guidelines, where feasible, to support medical providers in ensuring compassionate care during this often terminal event for this unique patient group.

The nature of learning from simulation: Now I know it, now I'll do it, I'll work on that.

CONTEXT: Ongoing learning in complex clinical environments requires health professionals to assess their own performance, manage their learning, and modify their practices based on self-monitored progress. Self-regulated learning (SRL) theory suggests that although learners may be capable of such learning, they often need guidance to enact it effectively. Debriefings following simulation may be an ideal time to support learners' use of SRL in targeted areas, but the extent to which they are optimally fostering these practices has not been examined. METHODS: A qualitative study informed by grounded theory methodology was conducted in the context of three interprofessional in situ trauma simulations at our level 1 trauma centre. A total of 18 participants were interviewed both immediately and 5-6 weeks after the simulation experience. Transcripts were analysed using an iterative constant comparative approach to explore concepts and themes regarding the nature of learning from and after simulation. RESULTS: During initial interviews, there were many examples of acquired content knowledge and straightforward practice changes that might not require ongoing SRL to enact well in practice. However, even for skills identified as needing to be 'worked on,' SRL strategies were lacking. At follow-up interviews, some participants had evolved more specific learning goals and rudimentary plans for implementation and improvement, but suggested this was prompted by the study interview questions rather than the simulation debriefing itself. CONCLUSIONS: Overall, participants did not engage in fulsome development of SRL plans based on the simulation and debriefing; however, there were elements of SRL present, particularly after participants were given time to reflect on the interview questions and their own goals. This suggests that simulation training can support the use of SRL. However, debriefing approaches might be better optimised to take full advantage of the opportunity to encourage and foster SRL in practice after the simulation is over.

Morbidity and mortality conferences in general surgery: a narrative systematic review.

Background: In medical and surgical departments around the world, morbidity and mortality conferences (MMC) serve dual roles: they are cornerstones of quality-improvement programs and provide timely opportunities for education within the urgent context of clinical care. Despite the widespread adoption of MMCs, adverse events and preventable errors remain high or incompletely characterized, and opportunities to learn from and adjust to these events are frequently lost. This review examines the published literature on strategies to improve surgical MMCs. Methods: We searched OVID Medline, PubMed, Embase and CENTRAL. We defined our combination of search terms using a PICO (population, intervention, comparison, outcome) model, focusing on the use of MMCs in general surgery. Results: The MMC literature focused on 5 themes: educational value, error analysis, case selection and representation, attendance and dissemination. Strategies used to increase educational value included limiting case presentation time to 15-20 minutes, mandatory brief literature reviews, increasing audience interaction, and standardizing presentations using a PowerPoint template or SBAR (situation, background, assessment, recommendation) format. Interventions to improve error analysis included focused discussion on causative factors and taxonomic error analysis. Case selection was improved by using an electronic clinical registry, such as the National Surgery Quality Improvement Program, to better capture incidence of morbidity and mortality. Attendance was improved with teleconferencing. Dissemination strategies included MMC newsletters, incorporating MMCs into plan-do-check-act cycles, and surgeon report cards. Conclusion: Greater standardization of best practices may increase the quality improvement and educational impact of MMCs and provide a baseline to measure the effect of new MMC format innovations on the clinical and educational performance of surgical systems.

Contexte: Dans les services de médecine et de chirurgie du monde entier, les conférences sur la morbidité et la mortalité (CMM) jouent 2 rôles : elles forment la pierre angulaire des programmes d'amélioration de la qualité de soins et fournissent l'occasion de faire de l'enseignement dans le contexte même des soins cliniques immédiats. Malgré la popularité grandissante des CMM, le nombre d'événements indésirables et d'erreurs évitables demeure élevé ou mal caractérisé et on perd beaucoup d'occasions d'apprendre de ces événements et d'apporter les changements qui s'imposent. La présente revue analyse la littérature publiée sur les stratégies d'amélioration des CMM en chirurgie. Méthodes: Nous avons interrogé OVID Medline, PubMed, Embase et CENTRAL. Nous avons défini nos combinaisons de mots clés à l'aide du modèle PICO (population, intervention, comparaison et résultat [outcome]), en mettant l'accent sur l'utilisation des CMM en chirurgie générale. Résultats: La littérature sur les CMM se concentrait sur 5 thèmes : valeur didactique, analyse des erreurs, sélection et représentation des cas, participation et dissémination. Les stratégies utilisées pour accroître la valeur didactique incluaient limiter la durée des présentations de cas à 15­20 minutes, présenter de brèves revues de la littérature, favoriser les interactions avec l'auditoire et standardiser les présentations au moyen de modèles PowerPoint ou SBAR (situation, background, assessment, recommendation). Les interventions visant à améliorer l'analyse des erreurs incluaient une discussion sur les facteurs causaux et l'analyse des erreurs taxonomiques. La sélection des cas a été améliorée au moyen d'un registre clinique électronique comme le National Surgery Quality Improvement Program, pour mieux suivre l'incidence de la morbidité et de la mortalité. Les systèmes de téléconférences ont amélioré la participation. Parmi les stratégies de dissémination, mentionnons les bulletins sur les CMM, leur intégration aux cycles planifier/faire/vérifier/agir et les relevés de notes des chirurgiens. Conclusion: Une meilleure standardisation des pratiques optimales pourrait améliorer davantage la qualité des soins et augmenter l'impact didactique des CMM en plus d'offrir une base de référence pour mesurer l'effet des nouvelles mesures appliquées aux CMM sur le rendement clinique et didactique des systèmes chirurgicaux.

Maternal and community predictors of gastroschisis and congenital diaphragmatic hernia in Canada.

PURPOSE: The incidence of gastroschisis (GS) has increased globally. Maternal age and smoking are risk factors and aboriginal communities may be more commonly affected. Factors leading to this increased incidence are otherwise unclear. We investigate maternal sociodemography, air pollution and personal risk factors comparing mothers of infants with GS with a control group of infants with diaphragmatic hernia (CDH) in a large population-based analysis. METHODS: Data were collected from a national, disease-specific pediatric surgical database (May 2006-June 2013). Maternal community sociodemographic information was derived from the Canadian 2006 Census. Univariate and multivariable analyses were performed examining maternal factors related to diagnosis of GS. RESULTS: GS infants come from poorer, less educated communities with more unemployment, less pollution, fewer immigrants, and more aboriginal peoples than infants with CDH. Teen maternal age, smoking, and illicit drug use, are associated with GS. CONCLUSION: Mothers of infants with GS are younger, more likely to smoke and come from socially disadvantaged communities with higher proportions of aboriginal peoples but lower levels of air pollution compared to mothers of CDH infants. Identification of maternal risks provides direction for prenatal screening and public health interventions.

Satisfaction and attrition in Canadian surgical training program leadership: a survey of program directors.

BACKGROUND: Surgical program directors (PDs) play an integral role in the well-being and success of postgraduate trainees. Although studies about medical specialties have documented factors contributing to PD burnout, early attrition rates and contributory factors among surgical PDs have not yet been described. We aimed to evaluate Canadian surgical PD satisfaction, stressors in the role and areas institutions could target to improve PD support. METHODS: We administered a cross-sectional survey of postgraduate Canadian surgical PDs from all Royal College of Physicians and Surgeons of Canada accredited surgical specialties. Domains we assessed included PD demographics and compensation, availability of administrative support, satisfaction with the PD role and factors contributing to PD challenges and burnout. RESULTS: Sixty percent of eligible surgical PDs (81 out of 134) from all 12 surgical specialties responded to the survey. We found significant heterogeneity in PD tenure, compensation models and available administrative support. All respondents reported exceeding their weekly protected time for the PD position, and 66% received less than 0.8 full-time equivalent of administrative support. One-third of respondents were satisfied with overall compensation, whereas 43% were unhappy with compensatory models. Most respondents (70%) enjoyed many aspects of the PD role, including relationships with trainees and shaping the education of future surgeons. Significant stressors included insufficient administrative support, complexities in resident remediation and inadequate compensation, which contributed to 37% of PDs having considered leaving the post prematurely. INTERPRETATION: Most surgical PDs enjoyed the role. However, intersecting factors such as disproportionate time demands, lack of administrative support and inadequate compensation for the role contributed to significant stress and risk of early attrition.

Telehealth application in Sudan: requirements and potential benefits.

Telehealth (TH) is defined as the entire spectrum of activities used to deliver care remotely. It could either be provider-to-patient or provider-to-provider communications. TH can take place synchronously (via telephone and video), asynchronously (via patient portal messages, e-consults), and through virtual agents (chat) and wearable devices. It has been used to support access to specialised medical advice in remote areas in many countries all over the world. We discuss the potential use of TH Clinics in Sudan and propose guidance for establishing such services. The current pandemic of SARS-COVID-19 has increased the pressure on most health systems. This has challenged and urged for significant changes in the way we provide health care for both COVID and non-COVID cases. There is a great potential for improvement in services in many countries including Sudan with the use of TH.

Rectal Cancer Metastasis to the Anal Verge: An Unusual Case Presentation and Review of the Literature.

BACKGROUND: Anal metastasis of colorectal adenocarcinoma is very rare, represented by only a handful of case reports in the literature. Previously, reports of metastasis to this region had occurred following a history of anorectal disease, such as anal fistulae. Antecedent trauma to the area from hemorrhoidectomy, fissures, or perineal retractor injury have also been implicated. CASE PRESENTATION: Herein we report the case of 69-year-old man without any history of anal disease presenting with a metachronous metastasis of a colorectal-type adenocarcinoma to the anal verge. He was previously treated for T1N0 rectal adenocarcinoma at the rectosigmoid junction with a low anterior resection 5 years prior, then had a T3N0 local recurrence at the colorectal anastomosis treated with neoadjuvant chemoradiation, and eventually a Hartmann's procedure 4 years later. Subsequently, on surveillance flexible sigmoidoscopy, a new tumor was identified on the perianal skin extending from the anal verge. Histopathology demonstrated colorectal-type adenocarcinoma. Flexible endoscopy identified no other residual or recurrent disease in the colon or rectal stump. The patient was treated with wide local excision and advancement flap reconstruction. CONCLUSION: Isolated metastasis to the anus is an extremely rare occurrence for colorectal adenocarcinoma. There exists little evidence to inform management. One option is to treat like a locally recurrent rectal cancer with aggressive tri-modality management consisting of chemoradiation, abdominal perineal resection, and adjuvant chemotherapy. In the absence of metastatic disease, local resection and close surveillance remain an option. As always, patient factors should guide management.

Ruptured Middle Colic Artery Aneurysm Presenting with Symptoms of Acute Cholecystitis: A Case Report and Literature Review.

Background: Ruptured middle colic artery aneurysm is extremely uncommon. Diagnosis can be challenging, as symptomatology can be attributed to more common abdominal pathologies. Due to the rarity of this condition, only case reports are available to inform management. Case Presentation: We present the case of a 72-year-old woman with a ruptured middle colic artery aneurysm presenting with signs and symptoms more suggestive of acute calculous cholecystitis. Her co-existing bleed was confirmed on CT angiogram. Coil embolization was initially attempted unsuccessfully. She underwent laparotomy, a middle colic artery ligation, and extended right hemicolectomy with intra-aortic balloon placement for emergency proximal vascular control. Post-operatively, she had a re-bleed that was successfully managed with covered stent placement in the proximal superior mesenteric artery after an unsuccessful re-attempt at coil embolization. Her apparent associated cholecystitis was managed with antibiotics and resolved uneventfully. Conclusion: A middle colic artery aneurysm can be challenging to diagnose and treat. Management options include endovascular techniques, open surgery, or a combination approach. Intra-aortic balloon placement for emergency vascular control is a novel approach that could avoid hemorrhage when intra-abdominal vascular access is challenging.

Quality of Colon Cancer Care in Patients Undergoing Emergency Surgery.

Thirty percent of colon cancer diagnoses occur following emergency presentations, often with bowel obstruction or perforation requiring urgent surgery. We sought to compare cancer care quality between patients receiving emergency versus elective surgery. We conducted an institutional retrospective matched (46 elective:23 emergency; n = 69) case control study. Patients who underwent a colon cancer resection from January 2017 to February 2019 were matched by age, sex, and cancer stage. Data were collected through the National Surgical Quality Improvement Program and chart review. Process outcomes of interest included receipt of cross-sectional imaging, CEA testing, pre-operative cancer diagnosis, pre-operative colonoscopy, margin status, nodal yield, pathology reporting, and oncology referral. No differences were found between elective and emergency groups with respect to demographics, margin status, nodal yield, oncology referral times/rates, or time to pathology reporting. Patients undergoing emergency surgery were less likely to have CEA levels, CT staging, and colonoscopy (p = 0.004, p = 0.017, p < 0.001). Emergency cases were less likely to be approached laparoscopically (p = 0.03), and patients had a longer length of stay (p < 0.001) and 30-day readmission rate (p = 0.01). Patients undergoing emergency surgery receive high quality resections and timely post-operative referrals but receive inferior peri-operative workup. The adoption of a hybrid acute care surgery model including short-interval follow-up with a surgical oncologist or colorectal surgeon may improve the quality of care that patients with colon cancer receive after acute presentations. Surgeons treating patients with colon cancer emergently can improve their care quality by ensuring that appropriate and timely disease evaluation is completed.

Learning After the Simulation Is Over: The Role of Simulation in Supporting Ongoing Self-Regulated Learning in Practice.

The complex and dynamic nature of the clinical environment often requires health professionals to assess their own performance, manage their learning, and modify their practices based on self-monitored progress. Self-regulated learning studies suggest that while learners may be capable of such in situ learning, they often need guidance to enact it effectively. In this Perspective, the authors argue that simulation training may be an ideal venue to prepare learners for self-regulated learning in the clinical setting but may not currently be optimally fostering self-regulated learning practices. They point out that current simulation debriefing models emphasize the need to synthesize a set of identified goals for practice change (what behaviors might be modified) but do not address how learners might self-monitor the success of their implementation efforts and modify their learning plans based on this monitoring when back in the clinical setting. The authors describe the current models of simulation-based learning implied in the simulation literature and suggest potential targets in the simulation training process, which might be optimized to allow medical educators to take full advantage of the opportunity simulation provides to support and promote ongoing self-regulated learning in practice.

Evidence-Based Strategies for the Treatment of Peritoneal Malignancies during Health Care Resource Restriction: The COVID-19 Pandemic.

Background: The COVID-19 pandemic has put enormous pressure on hospital resources, and has affected all aspects of patient care. As operative volumes decrease, cancer surgeries must be triaged and prioritized with careful thought and attention to ensure maximal benefit for the maximum number of patients. Peritoneal malignancies present a unique challenge, as surgical management can be resource intensive, but patients have limited non-surgical treatment options. This review summarizes current data on outcomes and resource utilization to help inform decision-making and case prioritization in times of constrained health care resources. Methods: A rapid literature review was performed, examining surgical and non-surgical outcomes data for peritoneal malignancies. Narrative data synthesis was cross-referenced with relevant societal guidelines. Peritoneal malignancy surgeons and medical oncologists reviewed recommendations to establish a national perspective on case triage and mitigating treatment strategies. Results and Conclusions: Triage of peritoneal malignancies during this time of restricted health care resource is nuanced and requires multidisciplinary discussion with consideration of individual patient factors. Prioritization should be given to patients where delay may compromise resectability of disease, and where alternative treatment options are lacking. Mitigating strategies such as systemic chemotherapy and/or surgical deferral may be utilized with close surveillance for disease stability or progression, which may affect surgical urgency. Unique hospital capacity, and ability to manage the complex post-operative course for these patients must also be considered to ensure patient and system needs are aligned.

The tetraspanin Tm4sf3 is localized to the ventral pancreas and regulates fusion of the dorsal and ventral pancreatic buds.

During embryogenesis, the pancreas develops from separate dorsal and ventral buds, which fuse to form the mature pancreas. Little is known about the functional differences between these two buds or the relative contribution of cells derived from each region to the pancreas after fusion. To follow the fate of dorsal or ventral bud derived cells in the pancreas after fusion, we produced chimeric Elas-GFP transgenic/wild-type embryos in which either dorsal or ventral pancreatic bud cells expressed GFP. We found that ventral pancreatic cells migrate extensively into the dorsal pancreas after fusion, whereas the converse does not occur. Moreover, we found that annular pancreatic tissue is composed exclusively of ventral pancreas-derived cells. To identify ventral pancreas-specific genes that may play a role in pancreatic bud fusion, we isolated individual dorsal and ventral pancreatic buds, prior to fusion, from NF38/39 Xenopus laevis tadpoles and compared their gene expression profiles (NF refers to the specific stage of Xenopus development). As a result of this screen, we have identified several new ventral pancreas-specific genes, all of which are expressed in the same location within the ventral pancreas at the junction where the two ventral pancreatic buds fuse. Morpholino-mediated knockdown of one of these ventral-specific genes, transmembrane 4 superfamily member 3 (tm4sf3), inhibited dorsal-ventral pancreatic bud fusion, as well as acinar cell differentiation. Conversely, overexpression of tm4sf3 promoted development of annular pancreas. Our results are the first to define molecular and behavioral differences between the dorsal and ventral pancreas, and suggest an unexpected role for the ventral pancreas in pancreatic bud fusion.