Association between Complications and Death within 30 days after General Surgery: A Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) substudy.

OBJECTIVE: To determine the epidemiology of post-operative complications among general surgery patients, inform their relationships with 30-day mortality, and determine the attributable fraction of death of each postoperative complication. BACKGROUND: The contemporary causes of post-operative mortality among general surgery patients are not well characterized. METHODS: VISION is a prospective cohort study of adult non-cardiac surgery patients across 28 centres in 14 countries, who were followed for 30 days after surgery. For the subset of general surgery patients, a cox proportional hazards model was used to determine associations between various surgical complications and post-operative mortality. The analyses were adjusted for preoperative and surgical variables. Results were reported in adjusted hazard ratios (HR) with 95% confidence intervals (CI). RESULTS: Among 7950 patients included in the study, 240 (3.0%) patients died within 30 days of surgery. Five post-operative complications (myocardial injury after non-cardiac surgery [MINS], major bleeding, sepsis, stroke, and acute kidney injury resulting in dialysis) were independently associated with death. Complications associated with the largest attributable fraction (AF) of post-operative mortality (i.e., percentage of deaths in the cohort that can be attributed to each complication, if causality were established) were major bleeding (n=1454, 18.3%, HR 2.49 95%CI 1.87-3.33, P<0.001, AF 21.2%), sepsis (n=783, 9.9%, HR 6.52, 95%CI 4.72-9.01, P<0.001, AF 15.6%), and MINS (n=980, 12.3%, HR 2.00, 95%CI 1.50-2.67, P<0.001, AF 14.4%). CONCLUSION: The complications most associated with 30-day mortality following general surgery are major bleeding, sepsis, and MINS. These findings may guide the development of mitigating strategies, including prophylaxis for perioperative bleeding.

Trauma resident exposure in Canada and operative numbers (TraumaRECON): a national multicentre retrospective review of operative and nonoperative trauma teaching.

BACKGROUND: General surgeons play an important role in the provision of trauma care in Canada and the current extent of their trauma experience during training is unknown. We sought to quantify the operative and nonoperative educational experiences among Canadian general surgery trainees. METHODS: We conducted a multicentre retrospective study of major operative exposures experienced by general surgery residents, as identified using institutional trauma registries and subsequent chart-level review, for 2008-2018. We also conducted a site survey on trauma education and structure. RESULTS: We collected data on operative exposure for general surgery residents from 7 programs and survey data from 10 programs. Operations predominantly occurred after hours (73% after 1700 or on weekends) and general surgery residents were absent from a substantial proportion (25%) of relevant trauma operations. The structure of trauma education was heterogeneous among programs, with considerable site-specific variability in the involvement of surgical specialties in trauma care. During their training, graduating general surgery residents each experienced around 4 index trauma laparotomies, 1 splenectomy, 1 thoracotomy, and 0 neck explorations for trauma. CONCLUSION: General surgery residents who train in Canada receive variable and limited exposure to operative and nonoperative trauma care. These data can be used as a baseline to inform the application of competency-based medical education in trauma care for general surgery training in Canada.

Redefining Trauma Training in Canada: A National Delphi Study on Curriculum, Educational Resources, and Training Initiatives.

OBJECTIVE: This study aims to develop a set of curriculum recommendations to support trauma training in Canadian general surgery residency programs. DESIGN: A modified Delphi study was conducted with a panel of trauma and surgical education experts. Proposed curriculum components were developed from Canadian trauma surgery exposure and educational needs assessment data. Panelists were asked to rate each potential curriculum component for inclusion (mandatory or exemplary) or exclusion in the ideal and feasible trauma training curriculum. SETTING: This national Delphi study was conducted in the Canadian trauma education context. PARTICIPANTS: A panel of trauma experts and surgeons holding leadership positions in training programs and professional societies across Canada were invited to participate. RESULTS: Nineteen panelists representing all geographic regions of Canada achieved consensus on a set of curriculum components. The panel was largely in agreement with the RCPSC trauma competencies. At the end of the study, 71 items were considered mandatory for all programs (such as dedicated trauma rotations, trauma resuscitation and operative skills courses, structured trauma teaching within academic half day, and simulation experiences), and 21 items were considered exemplary (such as program funding for trauma courses, and opportunities to participate in trauma research and quality improvement projects). CONCLUSIONS: This study suggests a framework of education components for curricular reform for trauma training in Canadian general surgery residency programs. Such recommendations include rotations, formal courses and certifications, education resources, and simulation experiences to supplement limited clinical exposure.

Delayed Versus Early Laparoscopic Appendectomy for Adult Patients With Acute Appendicitis: A Randomized Controlled Trial.

OBJECTIVE: To assess whether delaying appendectomy until the following morning is non-inferior to immediate surgery in those with acute appendicitis presenting at night. BACKGROUND: Despite a lack of supporting evidence, those with acute appendicitis who present at night frequently have surgery delayed until the after morning. METHODS: The delay trial is a noninferiority randomized controlled trial conducted between 2018 and 22 at 2 tertiary care hospitals in Canada. Adults with imaging confirmed acute appendicitis who presented at night (8:00 pm -4:00 am ). Delaying surgery until after 6:00 am was compared with immediate surgery. The primary outcome was 30-day postoperative complications. An a prior noninferiority margin of 15% was deemed clinically relevant. RESULTS: One hundred twenty-seven of the planned 140 patients were enrolled in the Delayed Versus Early Laparoscopic Appendectomy (DELAY) trial (59 in the delayed group and 68 in the immediate group). The two groups were similar at baseline. The mean time between the decision to operate and surgery was longer in the delayed group (11.0 vs 4.4 hours, P < 0.0001). The primary outcome occurred in 6/59 (10.2%) of those in the delayed group versus 15/67 (22.4%) of those in the immediate group ( P = 0.07). The difference between groups met the a priori noninferiority criteria of +15% (risk difference -12.2%, 95% CI: -24.4% to +0.4%, test of noninferiority P < 0.0001). CONCLUSIONS: The DELAY study is the first trial to assess delaying appendectomy in those with acute appendicitis. We demonstrate the noninferiority of delaying surgery until the after morning.

When is it safe to start venous thromboembolism prophylaxis after blunt solid organ injury? A prospective American Association for the Surgery of Trauma multi-institutional trial.

BACKGROUND: The optimal time to initiate venous thromboembolism (VTE) chemoprophylaxis (VTEp) after blunt solid organ injury remains controversial, as VTE mitigation must be balanced against bleeding promulgation. Evidence from primarily small, retrospective, single-center work suggests that VTEp ≤48 hours is safe and effective. This study was undertaken to validate this clinical practice. METHODS: Blunt trauma patients presenting to 19 participating trauma centers in North America were screened over a 1-year study period beginning between August 1 and October 1, 2021. Inclusions were age older than 15 years; ≥1 liver, spleen, or kidney injury; and initial nonoperative management. Exclusions were transfers, emergency department death, pregnancy, and concomitant bleeding disorder/anticoagulation/antiplatelet medication. A priori power calculation stipulated the need for 1,158 patients. Time of VTEp initiation defined study groups: Early (≤48 hours of admission) versus Late (>48 hours). Bivariate and multivariable analyses compared outcomes. RESULTS: In total, 1,173 patients satisfied the study criteria with 571 liver (49%), 557 spleen (47%), and 277 kidney injuries (24%). The median patient age was 34 years (interquartile range, 25-49 years), and 67% (n = 780) were male. The median Injury Severity Score was 22 (interquartile range, 14-29) with Abbreviated Injury Scale Abdomen score of 3 (interquartile range, 2-3), and the median American Association for the Surgery of Trauma grade of solid organ injury was 2 (interquartile range, 2-3). Early VTEp patients (n = 838 [74%]) had significantly lower rates of VTE (n = 28 [3%] vs. n = 21 [7%], p = 0.008), comparable rates of nonoperative management failure (n = 21 [3%] vs. n = 12 [4%], p = 0.228), and lower rates of post-VTEp blood transfusion (n = 145 [17%] vs. n = 71 [23%], p = 0.024) when compared with Late VTEp patients (n = 301 [26%]). Late VTEp was independently associated with VTE (odd ratio, 2.251; p = 0.046). CONCLUSION: Early initiation of VTEp was associated with significantly reduced rates of VTE with no increase in bleeding complications. Venous thromboembolism chemoprophylaxis initiation ≤48 hours is therefore safe and effective and should be the standard of care for patients with blunt solid organ injury. LEVEL OF EVIDENCE: Therapeutic and Care Management; Level III.

Association Between Complications after Vascular Surgery and Prolonged Postoperative Opioid Use.

BACKGROUND: Few studies have looked at the long-term risk of opioid use following major vascular surgery and no study has investigated the potential association between major complications and prolonged opioid use. We analyzed a population-based database linked to a prescription database to investigate factors associated with prolonged opioid use following major vascular surgery. METHODS: This population-based cohort study included all adults who underwent open lower extremity revascularization (LER) or nonruptured abdominal aortic aneurysm repair (open [AAA] and endovascular [EVAR]) in the province of Ontario, Canada, between 2013 and 2018. Prolonged opioid use was defined as 2 or more opioid prescriptions filled 6-12 months following surgery. Potential predictors of prolonged use were explored using modified Poisson regression with a generalized estimating equation approach to account for the clustering of patients within physicians and institutions. RESULTS: This study included a total of 11,104 patients with 5,652 patients undergoing open LER, 3,285 patients undergoing EVAR, and 2,167 patients undergoing AAA. The rates of prior opioid use were 35.4% for LER, 15.8% for AAA and 14.3% for EVAR. Major complication rates following each procedure were 59.5% for AAA, 35.1% for LER, and 21.0% for EVAR. Following surgery, prolonged opioid use was identified in 26.1% of LER, 13.2% of AAA, and 11.6% of EVAR patients. The strongest predictor of prolonged opioid use was prior use with an odds ratio (OR) of 13.27 (95% CI: 10.63-16.57) for AAA, 11.24 (95% CI: 9.18-13.75) for EVAR, and 4.69 (95% CI: 4.16-5.29) for LER. The occurrence of a major complication was only associated with prolonged opioid use for patients undergoing LER (OR 1.10; 95% CI: 1.03-1.19), while it had a protective effect on patients undergoing EVAR (OR 0.83; 95% CI: 0.69-0.99) and no association for patients undergoing open AAA repair (OR 1.11; 95% CI: 0.95-1.29). Older age was also protective with a reduced rate of prolonged opioid use for every 10 years of age increase: AAA (OR 0.87; 95% CI: 0.77-0.99); EVAR (OR 0.83; 95% CI: 0.76-0.91); and LER (OR 0.91; 95% CI: 0.87-0.94). CONCLUSIONS: Prolonged opioid use is common following major vascular surgery, occurring in over 10% of patients undergoing either open or endovascular aneurysm repair and over 25% of patients undergoing open LER. Prior opioid use is the strongest predictor for prolonged use, while the occurrence of postoperative complications is associated with a slight increased risk of prolonged use in patients undergoing LER. These patient populations should be targeted for multimodal methods of opioid reduction following their procedures.

Who are the trauma team leaders across Canada? A national survey evaluating the profession in adult and pediatric level one trauma centres.

OBJECTIVES: Trauma Team Leaders (TTLs) are critical for coordinating and leading trauma resuscitations. This survey sought to characterize the demographics and professional practices of Canadian TTLs at level one trauma centres. As a secondary objective, this information will be utilized to inform the operational goals of the Trauma Association of Canada (TAC) TTL Committee. METHODS: A detailed survey, developed by the TAC board of directors and TTL committee leads, was sent to 225 TTLs across Canada's level one trauma centres. TTLs were identified via contacting trauma directors at each level one centre, in addition to public registry searches. This survey captured demographics, professional background, resuscitation practices, trauma team composition, and TTL involvement in trauma responses. RESULTS: The response rate was 41.7%. Mean respondent age was 42 (SD 7.4) and 71.0% were male. Most TTLs trained in emergency medicine (53.1%) or general surgery (25.5%); 63.8% underwent TTL training: either via a trauma surgery fellowship or TTL fellowship. All centres have a massive hemorrhage protocol implemented, and there is no large variation between the rates of use of cryoprecipitate and fibrinogen, nor the ratio of blood products transfused (2:1 vs 1:1). Most TTL respondents intend to participate in a TTL group associated with TAC (85.1%). CONCLUSION: The results of this survey will contribute to the recognition of TTLs as a crucial role in the initial phase of care of severely injured trauma patients and serves as the first publication to document professional backgrounds and practices of Canadian TTLs at level one trauma centres. All the information gathered via this survey will be used by the TAC TTL Committee, which will focus on several initiatives such as the dissemination of best practice guidelines and creation of a TTL stream at the TAC Annual Conference.

RéSUMé: OBJECTIFS: Les chefs d'équipe de traumatologie (TTL) sont essentiels pour coordonner et diriger les réanimations traumatiques. Cette enquête visait à caractériser la démographie et les pratiques professionnelles des TTL canadiens dans les centres de traumatologie de niveau 1. À titre d'objectif secondaire, cette information sera utilisée pour éclairer les objectifs opérationnels du Comité TTL de l'Association canadienne de traumatologie (ATC). MéTHODES: Un sondage détaillé, élaboré par le conseil d'administration de l'ATC et les responsables des comités de TTL, a été envoyé à 225 TTL dans les centres de traumatologie de niveau 1 du Canada. Les TTL ont été identifiés en contactant les directeurs de traumatologie de chaque centre de niveau 1, en plus des recherches dans le registre public. Cette enquête a porté sur la démographie, les antécédents professionnels, les pratiques de réanimation, la composition de l'équipe de traumatologie et la participation de la TTL aux réponses traumatologiques. RéSULTATS: Le taux de réponse était de 41,7 %. L'âge moyen des répondants était de 42 ans (ET 7,4) et 71,0 % étaient des hommes. La plupart des TTL ont suivi une formation en médecine d'urgence (53,1%) ou en chirurgie générale (25,5%); 63,8% ont suivi une formation TTL : soit via une bourse en chirurgie traumatologique ou une bourse TTL. Tous les centres ont mis en œuvre un protocole d'hémorragie massive, et il n'y a pas de grande variation entre les taux d'utilisation du cryoprécipité et du fibrinogène, ni entre le rapport des produits sanguins transfusés (2:1 vs 1:1). La plupart des répondants TTL ont l'intention de participer à un groupe TTL associé au TAC ( 85,1 %). CONCLUSION: Les résultats de ce sondage contribueront à la reconnaissance des TTL comme un rôle crucial dans la phase initiale des soins aux patients ayant subi un traumatisme grave et serviront de première publication pour documenter les antécédents et les pratiques professionnelles des TTL canadiens au niveau un centres de traumatologie. Toutes les informations recueillies dans le cadre de cette enquête seront utilisées par le Comité TAC TTL, qui se concentrera sur plusieurs initiatives telles que la diffusion de lignes directrices sur les meilleures pratiques et la création d'un flux TTL à la conférence annuelle TAC.

Defining major surgical complications using administrative data in Ontario: a validation study.

BACKGROUND: Although surgical complications are often included as an outcome of surgical research conducted using administrative data, little validation work has been performed. We sought to evaluate the diagnostic performance of an algorithm designed to capture major surgical complications using health administrative data. METHODS: This retrospective study included patients who underwent high-risk elective general surgery at a single institution in Ontario, Canada, from Sept. 1, 2016, to Sept. 1, 2017. Patients were identified for inclusion using the local operative database. Medical records were reviewed by trained clinicians to abstract postoperative complications. Data were linked to administrative data holdings, and a series of code-based algorithms were applied to capture a composite indicator of major surgical complications. We used sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy to evaluate the performance of our administrative data algorithm, as compared with data abstracted from the institutional charting system. RESULTS: The study included a total of 270 patients. According to the data from the chart audit, 55% of patients experienced at least 1 major surgical complication. Overall sensitivity, specificity, PPV, NPV and accuracy for the composite outcome was 72%, 80%, 82%, 70% and 76%, respectively. Diagnostic performance was poor for several of the individual complications. CONCLUSION: Our results showed that administrative data holdings can be used to capture a composite indicator of major surgical complications with adequate sensitivity and specificity. Additional work is required to identify suitable algorithms for several specific complications.

Establishing a core outcome set for blunt cerebrovascular injury: an EAST modified Delphi method consensus study.

Objectives: Our understanding of blunt cerebrovascular injury (BCVI) has changed significantly in recent decades, resulting in a heterogeneous description of diagnosis, treatment, and outcomes in the literature which is not suitable for data pooling. Therefore, we endeavored to develop a core outcome set (COS) to help guide future BCVI research and overcome the challenge of heterogeneous outcomes reporting. Methods: After a review of landmark BCVI publications, content experts were invited to participate in a modified Delphi study. For round 1, participants submitted a list of proposed core outcomes. In subsequent rounds, panelists used a 9-point Likert scale to score the proposed outcomes for importance. Core outcomes consensus was defined as >70% of scores receiving 7 to 9 and <15% of scores receiving 1 to 3. Feedback and aggregate data were shared between rounds, and four rounds of deliberation were performed to re-evaluate the variables not achieving predefined consensus criteria. Results: From an initial panel of 15 experts, 12 (80%) completed all rounds. A total of 22 items were considered, with 9 items achieving consensus for inclusion as core outcomes: incidence of postadmission symptom onset, overall stroke incidence, stroke incidence stratified by type and by treatment category, stroke incidence prior to treatment initiation, time to stroke, overall mortality, bleeding complications, and injury progression on radiographic follow-up. The panel further identified four non-outcome items of high importance for reporting: time to BCVI diagnosis, use of standardized screening tool, duration of treatment, and type of therapy used. Conclusion: Through a well-accepted iterative survey consensus process, content experts have defined a COS to guide future research on BCVI. This COS will be a valuable tool for researchers seeking to perform new BCVI research and will allow future projects to generate data suitable for pooled statistical analysis with enhanced statistical power. Level of evidence: Level IV.

Impact of COVID-19 Pandemic on Readmission Rates Following Colorectal Surgery: A Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic placed increased pressure to discharge patients early; this could have resulted in rushed discharges requiring patients to return to hospital. The impact of the pandemic on readmission after colorectal surgery is unknown. METHODS: The National Surgical Quality Improvement Program (ACS-NSQIP) database was used to compare patients undergoing elective colorectal surgery in 2019 and 2020, prior to and during the COVID-19 pandemic. Multivariable logistic regression was used to examine variables associated with readmission. Propensity score matching was then used to compare patients in the pre-pandemic and pandemic cohorts. RESULTS: A total of 72,874 colorectal cases were included. There were 17.7% less cases in 2020. Rate of readmission was similar in both groups (9.6% vs. 9.4%). There were fewer patients discharged to a facility such as nursing facility or rehabilitation center in 2020, with more patients discharged home. Year was not associated with readmission on multivariable analysis. In the matched cohort, readmission rates did not differ (9.7% vs. 9.3% p = 0.129) nor did mortality (0.8% vs. 0.8% p = 0.686). CONCLUSIONS: No difference in readmission rates before or during the COVID-19 pandemic was observed; suggesting increased pressure to keep patients out of hospital in the COVID-19 pandemic did not result in patients being rushed home requiring repeat admission. More patients were discharged home with fewer to rehabilitation or nursing facilities in 2020, suggesting success with avoiding transitional services in the right setting.

Efficacy of high dose tranexamic acid (TXA) for hemorrhage: A systematic review and meta-analysis.

BACKGROUND: Standard dose (≤ 1 g) tranexamic acid (TXA) has established mortality benefit in trauma patients. The role of high dose IV TXA (≥2 g or ≥30 mg/kg as a single bolus) has been evaluated in the surgical setting, however, it has not been studied in trauma. We reviewed the available evidence of high dose IV TXA in any setting with the goal of informing its use in the adult trauma population. METHODS: We searched MEDLINE, EMBASE and unpublished sources from inception until July 27, 2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16 years of age) with hemorrhage. Screening and data abstraction was done independently and in duplicate. We pooled trial data using a random effects model and considered randomized controlled trials (RCTs) and observational cohort studies separately. We assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). RESULTS: We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml less, 95% CI 135.53 to 48.90 ml less, low certainty), and an uncertain effect on thromboembolic events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70, 95% CI 0.37 to 1.32, very low certainty). CONCLUSION: When compared to standard dose, high dose IV TXA probably reduces transfusion requirements with an uncertain effect on thromboembolic events and mortality. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level IV.

The next frontier of acute care general surgery: fellowship training.

Acute care surgery (ACS) is an area of surgical specialization within general surgery and a model for clinical care delivery that has proliferated over the last 2 decades. Models of ACS in Canada exist in both academic and community settings and are used to manage patients in need of emergency general surgery (EGS) care, with or without the provision of trauma care. The implementation of the ACS model has changed the landscape of patient care, surgical education and the workforce, providing an option for some general surgeons to exclude EGS care from their regular practice. The rise of ACS as a concentration of surgical skill and content expertise has resulted in the establishment of dedicated ACS fellowship training programs. This is a landmark in the evolution of general surgery, as well as a stepping stone on the path to improving patient care, surgical education and scholarly endeavour in this field.

Operating room use for emergency general surgery cases: analysis of the Patterns of Complex Emergency General Surgery in Canada study.

BACKGROUND: Access to the operating room (OR) is variable among emergency general surgery (EGS) services, with some having dedicated EGS ORs, and others only a shared queue. Currently in Canada, only a limited number of acute care surgery services have dedicated daytime operating room (OR) access; hence, we aimed to describe the burden of after-hours EGS operating in Canada and differences associated with OR access. METHODS: In this multicentre retrospective cohort study, we used data from a previously conducted study designed to evaluate nonappendiceal, nonbiliary disease across 8 Canadian hospitals. We performed a secondary analysis to describe booking priorities and timing of operative interventions, compare sites with and without access to a dedicated EGS daytime OR, and identify differences in morbidity and mortality based on timing of operative intervention. RESULTS: Among 1244 patients, operations were performed during weekday daytime in 521 cases (41.9%), in the evening in 279 (22.4%), on the weekend in 293 (23.6%) and overnight in 151 (12.1%). Operating room booking priority was more than 2 hours to 8 hours in 657 cases (52.8%), more than 8 hours to 24 hours in 334 (26.9%) and more than 24 hours to 48 hours in 253 (20.3%). Substantial variation in booking priority was observed for the same preoperative diagnoses. Sites with dedicated EGS ORs performed a greater proportion of cases during daytime versus overnight compared to sites without dedicated EGS ORs (198/237 [83.5%] v. 323/435 [74.2%], p = 0.006). No significant differences in outcome were found between cases performed during the daytime, evening and overnight. CONCLUSION: We found considerable variation in OR booking priority within the same preoperative diagnoses among EGS patients in Canada. Sites with dedicated EGS ORs performed more cases during weekday daytime compared to sites without dedicated EGS ORs; however, this study showed no evidence of compromised outcomes based on OR timing.

Rates, Predictive Factors, and Adverse Outcomes of Fusion Surgery for Lumbar Degenerative Disorders in Ontario, Canada, Between 2006 and 2015: A Retrospective Cohort Study.

BACKGROUND: The addition of fusion surgery to the decompression for lumbar degenerative disorders remains controversial. The purpose of this study is to compare the rate and outcome of decompression and fusion versus decompression alone. METHODS: This population-based retrospective cohort study used several linked administrative databases to identify patients who underwent spinal decompression surgery in Ontario, Canada, from 2006 to 2015. Patients who had previous spine surgery, concurrent lumbar disc replacement, or a diagnosis other than degenerative disc disease were excluded. Adjusted logistic regression was used to assess our outcomes. RESULTS: We identified 33,912 patients, of whom 9748 (28.74%) underwent fusion. Overall, fusion rates increased from 27.66% to 31.33% over the study period (P = 0.025). Factors associated with fusion included: older age, female sex, American Society of Anesthesiologists score ≥3, previous total joint replacement, and surgery by an orthopedic surgeon. Fusion surgery was associated with increased odds of 30-day mortality (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.01-3.09; P = 0.046), 30-day (OR 1.94, 95% CI 1.53-2.46; P < 0.0001) and 90-day reoperation (OR 1.66, 95% CI 1.35-2.05; P < 0.0001), and 30-day readmission (OR 1.23, 95% CI 1.02-1.49; P = 0.027) when adjusting for confounding variables. The odds of suffering a complication after fusion and decompression surgery vs. decompression surgery alone were 4.3-fold greater (95% CI 3.78-5.09; P < 0.0001). CONCLUSIONS: As compared with decompression alone, spinal fusion for degenerative lumbar disorders is associated with increased odds of adverse outcomes. These findings highlight the need for spine surgeons to consider carefully their indications for fusion procedures in the setting of degenerative spinal disorders.

Opioid use after outpatient elective general surgery: quantifying the burden of persistent use.

Purpose: Surgery is a major risk factor for chronic opioid use among patients who had not recently been prescribed opioids. This study identifies the rate of, and risk factors for, persistent opioid use following laparoscopic cholecystectomy and open inguinal hernia repair in patients not recently prescribed opioids. Methods: This retrospective population-based cohort study included all patients who had not been prescribed opioids in the 6 months prior to undergoing open inguinal hernia repair or laparoscopic cholecystectomy from January 2013 to July 2016 in Ontario. Opioid prescription was identified from the provincial Narcotics Monitoring System and data were obtained from the Institute for Clinical Evaluative Sciences. The primary outcome was persistent opioid use after surgery (3, 6, 9 and 12 months). Associated risk factors and prescribing patterns were also examined. Results: Among the 90,326 patients in the study cohort, 80% filled an opioid prescription after surgery, with 11%, 9%, 5% and 1% filling a prescription at 3, 6, 9 and 12 months, respectively. Significant variability was identified in the type of opioid prescribed (41% codeine, 31% oxycodone, 18% tramadol) and in regional prescribing patterns (mean prescription/region range, 135-225 oral morphine equivalents). Predictors of continued opioid use included age, female gender, lower income quintile and being operated on by less experienced surgeons. Conclusion: Most patients who undergo elective cholecystectomy and hernia repair will fill a prescription for an opioid after surgery, and many will continue to fill opioid prescriptions for considerably longer than clinically anticipated. There is important variability in opioid type, regional prescribing patterns and risk factors that identify strategic targets to reduce the opioid burden in this patient population.

Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS).

SummaryResuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

Failure to rescue in emergency general surgery in Canada.

BACKGROUND: The risk of death after a postoperative complication - known as failure to rescue (FTR) - has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres. METHODS: In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit). RESULTS: A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment. CONCLUSION: There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services.

Patient Sex and Postoperative Outcomes after Inpatient Intraabdominal Surgery: A Population-based Retrospective Cohort Study.

BACKGROUND: Intraabdominal surgeries are frequently performed procedures that lead to a high volume of unplanned readmissions and postoperative complications. Patient sex may be a determinant of adverse outcomes in this population, possibly due to differences in biology or care delivery, but it is understudied. The authors hypothesized that there would be no association between patient sex and the risk of postoperative adverse outcomes in intraabdominal surgery. METHODS: This retrospective, population-based cohort study involved adult inpatients aged 18 yr or older who underwent intraabdominal surgeries in Ontario, Canada, between April 2009 and March 2016. The authors studied the association of patient sex on the primary composite outcome of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days. Inverse probability of exposure weighting based on propensity scores (computed using demographic characteristics such as rural residence status and median neighborhood income quintile, common comorbidities, and surgery- and hospital-specific characteristics) was used to estimate the adjusted association of sex on outcomes. RESULTS: The cohort included 215,846 patients (52.3% female). The primary outcome was observed in 24,712 (21.9%) females and 25,486 (24.7%) males (unadjusted risk difference, 2.8% [95% CI, 2.5 to 3.2%]; P < 0.001). After adjustment, the association between the male sex and the primary outcome was not statistically significant (adjusted risk difference, -0.2% [95% CI, -0.5 to 0.2%]; P = 0.378). CONCLUSIONS: In a large population of intraabdominal surgical patients, there was no differential risk between sexes in the composite outcome of all-cause death, hospital readmission, or major postoperative complications, all within 30 postoperative days.