Laparoscopic Sac Disconnection and Peritoneal Closure of Pediatric Inguinal Hernia.

Background: Laparoscopic sac disconnection and peritoneal closure represents an alternative to open pediatric hernia repair. We performed a retrospective review of our data to evaluate this alternative method. Materials and Methods: With REB approval, a retrospective chart review of all patients who underwent laparoscopic indirect inguinal hernia repair between June 2013 and July 2016 was conducted. Primary outcome was the recurrence rate. Secondary outcomes included length of surgery, postoperative hydrocele, and perioperative complications. Data were extracted from EPIC Hyperspace onto a standardized data extraction form. Results: A total of 243 patients were included, of which 82% were males. Age ranged from 1 month to 17 years of age. A total of 322 defects were repaired. Eighty (32%) had contralateral patent processus vaginalis. Twelve (4%) patients presented with incarceration and three (1.2%) had a direct inguinal hernia defect. Recurrence rate was 0.6% (n = 2). There were no intraoperative complications. Operative time was an average of 40 and 54 minutes for unilateral and bilateral repairs, respectively. No testicular ascents, testicular atrophy, vas deferens injury, postoperative hydroceles, and wound infections were reported. Conclusion: Laparoscopic sac disconnection and peritoneal closure of pediatric inguinal hernia is a safe, feasible method with one of the lowest reported recurrence rate among the other laparoscopic methods.

Unscheduled general surgery has higher costs for older adults.

BACKGROUND: With health care costs increasing, the cost of caring for older adults is rising. Understanding the costs of surgical care for older adults is crucial in planning for health care services. We hypothesize that increasing age predicts increasing surgical inpatient costs. METHODS: We conducted a retrospective analysis of general surgical inpatient costs at 4 hospitals over 2 fiscal years. We assessed the cost and number of procedures by age, procedure, hospital, cost category and surgical urgency. Costs were compared between surgical risk profile, urgency and age. Cost differences of 10% or more were considered clinically important. RESULTS: We examined the surgical inpatient costs for 12 070 procedures, representing 84% of all admissions in the region. The average cost was $4351 for scheduled admissions and $4054 for unscheduled admissions. Only unscheduled admissions resulted in higher costs in older age groups, more than doubling in patients aged 80 years and older undergoing low- and moderate-risk unscheduled surgery. The higher costs for older adults was primarily because of higher postoperative costs. In addition, the screening of candidates for elective surgery may have resulted in preoperative medical optimization leading to decreased admission costs. CONCLUSION: Older adults requiring surgery incur increased costs only if admitted for emergency surgery. The cost increase associated with unscheduled admissions was primarily for increased postoperative costs. Innovative programs to reduce costs for postoperative care for older adults undergoing emergency surgery should be investigated.

Observation, Aspiration, or Tube Thoracostomy for Primary Spontaneous Pneumothorax: A Systematic Review, Meta-Analysis, and Cost-Utility Analysis.

BACKGROUND: Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled data comparing techniques has not been performed. RESEARCH QUESTION: Based on studies from the past 20 years, which approach to management of PSP delivers the highest utility? STUDY DESIGN AND METHODS: A systematic review of PSP management strategies (observation, aspiration, or chest tube placement) included in the Medline and EMBASE databases from January 1, 2000, through April 10, 2020, was conducted. Text screening, bias assessment, and data extraction were performed by two authors (G. E. and C. A. P.). Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution after the initial intervention. Secondary outcomes were PSP recurrence, length of stay, rate of surgical management, and complications. The meta-analysis compared treatment arms; dichotomous outcomes were reported as relative risk (RRs) and continuous outcomes were reported as mean differences. A cost-utility analysis within the Canadian health care system context with deterministic and probabilistic sensitivity analyses was performed. RESULTS: Five thousand one hundred seventy-nine articles were identified; after screening, 22 articles were included. Most trials showed a high risk of bias, but randomized trials showed a lower risk. Compared with chest tube placement, observation (mean difference, 5.17; 95% CI, 3.75-6.59; P < .01; I2 = 62%) and aspiration (mean difference, 2.72; 95% CI, 2.39-3.04; P < .01; I2 = 0%) showed a shorter length of stay. Compared with observation, chest tube placement (RR, 0.81; 95% CI, 0.71-0.91; P < .01; I2 = 62%) and aspiration (RR, 0.73; 95% CI, 0.61-0.88; P < .01; I2 = 67%) showed higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation showed the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte Carlo simulations. INTERPRETATION: Observation is the dominant choice compared with aspiration and chest tube placement for PSP. It should be considered as the first-line therapy in appropriately selected patients.

Cost effectiveness of the quality assurance and performance improvement project for suspected appendicitis study.

INTRODUCTION: Appendicitis is the most common pediatric emergent surgical condition, with 77,000 American pediatric admissions costing $680 million US annually. Diagnosing appendicitis can be challenging. The prospective Quality Assurance and performance improvement project for suspected aPPEndicitis (QAPPE) study implemented a standardized appendicitis assessment pathway. This current study aims to assess the cost-effectiveness of the QAPPE pathway. METHODS: QAPPE data (February 2018-January 2019) were compared to retrospective data from the year prior (January-December 2017). Patients aged <18, presenting with suspicion of appendicitis were identified using the emergency department patient database. Patients were excluded if they were transferred from an outside center or if appendicitis was not suspected. Study arms were compared using Student's t-test and assessed with standard costing techniques. The Incremental Cost-Effectiveness Ratio (ICER) was determined. Deterministic and probabilistic sensitivity analyses of the model were performed. Effectiveness was assessed by percent of negative appendectomies where alternate diagnosis was made intraoperatively or histologically. Significance was set at p < 0.05. RESULTS: QAPPE (n = 247) and traditional care (n = 234) patients were compared. Traditional care had higher admission frequency and lower pediatric appendicitis score. Demographics between all included patients and those admitted were similar overall. Patient costs were $3656.32 (95% CI $2407-$5250) Canadian (CAD) for QAPPE and $3823.56 (95% CI $2604-$5451) CAD for traditional care. QAPPE was the dominant strategy in the base model and probabilistic simulation found it favored in 64.7% of model iterations with a willingness to pay of $70,000 CAD. CONCLUSION: Using the QAPPE pathway to assess patients with suspected appendicitis reduced costs and improved effectiveness of patient care. LEVEL OF EVIDENCE: 2.

Conducting an international curriculum review meeting in the age of COVID-19.

SUMMARY: The Canadian Network for International Surgery (CNIS) hosted a workshop in May of 2020 with a goal of critically evaluating Trauma Team Training courses. The workshop was held virtually because of the coronavirus disease 2019 (COVID-19) pandemic. Twenty-three participants attended from 8 countries: Canada, Guyana, Kenya, Nigeria, Switzerland, Tanzania, Uganda and the United States. More participants were able to attend the virtual meeting than the traditional in-person meetings. Web-based videoconference software was used, participants presented prerecorded PowerPoint videos, and questions were raised using a written chat. The review proved successful, with discussions and recommendations for improvements surrounding course quality, lecture content, skills sessions, curriculum variations and clinical practical scenarios. The CNIS's successful experience conducting an online curriculum review involving international participants may prove useful to others proceeding with collaborative projects during the COVID-19 pandemic.

Frailty predicts increased costs in emergent general surgery patients: A prospective cohort cost analysis.

BACKGROUND: Aging populations have led to increasing numbers of seniors presenting for emergency surgery. Older patients are at a higher risk of postoperative complications, prolonged hospitalization, and increased institutionalization. We hypothesized that increased frailty would be a risk factor for increased health care costs in elderly surgical patients who have undergone emergency abdominal surgery. METHODS: A prospective cost analysis of emergency general surgery patients 65 years of age and older was conducted. Demographic and clinical characteristics were obtained. Preadmission Clinical Frailty Scale score and Clavien-Dindo postoperative complications were collected. Patients were followed for 6 months after discharge. Hospitalization costs were calculated using the Alberta Health Services (AHS) microcosting database; other costs were obtained from Alberta Health Services and Alberta Health databases. The primary outcome was total insured cost (2016 Can$). Multivariate generalized linear regression of log-transformed costs was conducted. RESULTS: Overall, 321 patients were enrolled. Mean age was 76.1 years (standard deviation 7.8), median Clinical Frailty Scale was 3, mean length of stay was 15.9 days (standard deviation 23.4), and 48% suffered a complication. Median total insured cost was Can$18,021 and median total cost was Can$26,739. Multivariate analysis found American Society of Anesthesiologists score (adjusted ratio [AR] = 1.24, P = .001), CFS (AR = 1.27, P < .001), major complications (AR = 2.11, P < .001), and minor complications (AR = 1.48, P < .001) lead to increased total insured costs. CONCLUSION: Costs increased-after adjusting for age, comorbidities, and preadmission function as frailty-and American Society of Anesthesiologists score increased if minor or major complications occurred. The detection of frailty represents an opportunity to target risk-reduction strategies and interventions to improve outcomes and decrease cost.

Review of risk assessment tools to predict morbidity and mortality in elderly surgical patients.

BACKGROUND: Informed surgical consent requires accurate estimation of risks and benefits. Multiple risk assessment tools are available; however, most are not widely used or are specific to certain interventions. Assessing surgical risk is especially challenging in elderly patients because of their range of comorbidities, level of frailty, or severity of illness and a number of available surgical interventions. DATA SOURCES: We searched MEDLINE from January 2014 to July 2017 for studies that used risk assessment tools in studies on elderly surgical patients. We then sought the original articles describing each assessment tool and subsequent validation studies. CONCLUSIONS: We identified risk assessment tools that can improve surgical risk assessment in elderly surgical patients. The majority of the identified tools are not commonly used for pre-operative risk assessment. NSQIP-PMP, mFI and SURPAS are promising tools. Age is commonly used to predict risk, but frailty may be a more appropriate measure.

Comprehensive geriatric assessment for older people admitted to a surgical service.

BACKGROUND: Aging populations are at increased risk of postoperative complications. New methods to provide care for older people recovering from surgery may reduce surgery-related complications. Comprehensive geriatric assessment (CGA) has been shown to improve some outcomes for medical patients, such as enabling them to continue living at home, and has been proposed to have positive impacts for surgical patients. CGA is a coordinated, multidisciplinary collaboration that assesses the medical, psychosocial and functional capabilities and limitations of an older person, with the goal of establishing a treatment plan and long-term follow-up. OBJECTIVES: To assess the effectiveness of CGA interventions compared to standard care on the postoperative outcomes of older people admitted to hospital for surgical care. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two clinical trials registers on 13 January 2017. We also searched grey literature for additional citations. SELECTION CRITERIA: Randomized trials of people undergoing surgery aged 65 years and over comparing CGA with usual surgical care and reporting any of our primary (mortality and discharge to an increased level of care) or secondary (length of stay, re-admission, total cost and postoperative complication) outcomes. We excluded studies if the participants did not receive a complete CGA, did not undergo surgery, and if the study recruited participants aged less than 65 years or from a setting other than an acute care hospital. DATA COLLECTION AND ANALYSIS: Two review authors independently screened, assessed risk of bias, extracted data and assessed certainty of evidence from identified articles. We expressed dichotomous treatment effects as risk ratio (RR) with 95% confidence intervals and continuous outcomes as mean difference (MD). MAIN RESULTS: We included eight randomised trials, seven recruited people recovering from a hip fracture (N = 1583) and one elective surgical oncology trial (N = 260), conducted in North America and Europe. For two trials CGA was done pre-operatively and postoperatively for the remaining. Six trials had adequate randomization, five had low risk of performance bias and four had low risk of detection bias. Blinding of participants was not possible. All eight trials had low attrition rates and seven reported all expected outcomes.CGA probably reduces mortality in older people with hip fracture (RR 0.85, 95% CI 0.68 to 1.05; 5 trials, 1316 participants, I² = 0%; moderate-certainty evidence). The intervention reduces discharge to an increased level of care (RR 0.71, 95% CI 0.55 to 0.92; 5 trials, 941 participants, I² = 0%; high-certainty evidence).Length of stay was highly heterogeneous, with mean difference between participants allocated to the intervention and the control groups ranging between -12.8 and 8.3 days. CGA probably leads to slightly reduced length of stay (4 trials, 841 participants, moderate-certainty evidence). The intervention probably makes little or no difference in re-admission rates (RR 1.00, 95% CI 0.76 to 1.32; 3 trials, 741 participants, I² = 37%; moderate-certainty evidence).CGA probably slightly reduces total cost (1 trial, 397 participants, moderate-certainty evidence). The intervention may make little or no difference for major postoperative complications (2 trials, 579 participants, low-certainty evidence) and delirium rates (RR 0.75, 95% CI 0.60 to 0.94, 3 trials, 705 participants, I² = 0%; low-certainty evidence). AUTHORS' CONCLUSIONS: There is evidence that CGA can improve outcomes in people with hip fracture. There are not enough studies to determine when CGA is most effective in relation to surgical intervention or if CGA is effective in surgical patients presenting with conditions other than hip fracture.

Analysis of postdischarge costs following emergent general surgery in elderly patients.

BACKGROUND: As populations age, more elderly patients will undergo surgery. Frailty and complications are considered to increase in-hospital cost in older adults, but little is known on costs following discharge, particularly those borne by the patient. We examined risk factors for increased cost and the type of costs accrued following discharge in elderly surgical patients. METHODS: Acute abdominal surgery patients aged 65 years and older were prospectively enrolled. We assessed baseline clinical characteristics, including Clinical Frailty Scale (CFS) scores. We calculated 6-month cost (in Canadian dollars) from patient-reported use following discharge according to the validated Health Resource Utilization Inventory. Primary outcomes were 6-month overall cost and cost for health care services, medical products and lost productive hours. Outcomes were log-transformed and assessed in multivariable generalized linear and zero-inflated negative binomial regressions and can be interpreted as adjusted ratios (AR). Complications were assessed according to Clavien-Dindo classification. RESULTS: We included 150 patients (mean age 75.5 ± 7.6 yr; 54.1% men) in our analysis; 10.8% had major and 43.2% had minor complications postoperatively. The median 6-month overall cost was $496 (interquartile range $140-$1948). Disaggregated by cost type, frailty independently predicted increasing costs of health care services (AR 1.76, 95% confidence interval [CI] 1.43-2.18, p < 0.001) and medical products (AR 1.61, 95% CI 1.15-2.25, p = 0.005), but decreasing costs in lost productive hours (AR 0.39, p = 0.002). Complications did not predict increased cost. CONCLUSION: Frail patients accrued higher health care services and product costs, but lower costs from lost productive hours. Interventions in elderly surgical patients should consider patient-borne cost in older adults and lost productivity in less frail patients. TRIAL REGISTRATION: NCT02233153 (clinicaltrials.gov).

CONTEXTE: Avec le vieillissement de la population, les personnes âgées seront plus nombreuses à subir des chirurgies. Il est déjà reconnu que la fragilité et les complications font augmenter les coûts d'hospitalisation chez les adultes âgés, mais on en sait relativement peu sur les coûts posthospitaliers, particulièrement ceux assumés par le patient lui-même. Nous avons analysé les facteurs de risque d'augmentation de ces coûts et les types de dépenses assumées après le congé par les patients âgés opérés. MÉTHODES: Pour l'étude, nous avons recruté des patients de 65 ans et plus qui allaient subir une chirurgie abdominale d'urgence. Nous avons déterminé leurs caractéristiques cliniques initiales, y compris leur score à l'échelle de fragilité clinique (EFC). Nous avons calculé les coûts échelonnés sur 6 mois (en dollars canadiens) rapportés par les patients après leur congé, selon un inventaire validé de l'utilisation des ressources de santé. Les paramètres principaux étaient le montant total des dépenses et le coût des services de santé, des produits médicaux et des heures de travail perdues pour une période de 6 mois. Une transformation logarithmique a été appliquée aux données, qui ont été évaluées par une analyse de régression linéaire multivariée généralisée et par une analyse binomiale négative avec surreprésentation des zéros. Les résultats peuvent être interprétés comme des rapports ajustés (RA). Les complications ont été évaluées selon la classification de Clavien-Dindo. RÉSULTATS: Nous avons inclus 150 patients dans notre analyse (âge moyen : 75,5 ± 7,6 ans; proportion d'hommes : 54,1 %). Après l'opération, 10,8 % ont présenté des complications majeures, et 43,2 %, des complications mineures. Le montant total médian des dépenses sur 6 mois était de 496 $ (éventail interquartile : 140-1948 $). Dans des analyses effectuées selon le type de dépenses, la fragilité était une variable explicative permettant de prédire indépendamment l'accroissement des coûts des services de santé (RA : 1,76; intervalle de confiance [IC] à 95 % : 1,43-2,18; p < 0,001) et des produits médicaux (RA : 1,61; IC à 95 % : 1,15-2,25; p = 0,005) ainsi que la réduction des coûts associés aux heures de travail perdues (RA : 0,39; p = 0,002). Les complications n'avaient pas de valeur prédictive en ce qui a trait à l'accroissement des coûts. CONCLUSION: Les patients fragiles ont assumé des coûts plus élevés en services de santé et en produits médicaux, mais des coûts moindres en lien avec la perte d'heures de travail. Les interventions chez les patients en chirurgie âgés devraient tenir compte des coûts assumés par cette population et de la perte de productivité chez les patients moins fragiles. ENREGISTREMENTDEL'ESSAI: ClinicalTrials.gov, no NCT02233153.

Economic evaluations of comprehensive geriatric assessment in surgical patients: a systematic review.

BACKGROUND: Seniors presenting with surgical disease face increased risk of postoperative morbidity and mortality and have increased treatment costs. Comprehensive Geriatric Assessment (CGA) is proposed to reduce morbidity, mortality, and the cost after surgery. METHODS: A systematic review of CGA in emergency surgical patients was conducted. The primary outcome was cost-effectiveness; secondary outcomes were length of stay, return of function, and mortality. Inclusion and exclusion criteria were predefined. Systematic searches of MEDLINE, Embase, Cochrane, and National Health Service Economic Evaluation Database were performed. Text screening, bias assessment, and data extraction were performed by two authors. RESULTS: There were 560 articles identified; abstract review excluded 499 articles and full-text review excluded 53 articles. Eight studies were included; one nonorthopedic trauma and seven orthopedic trauma studies. Bias assessment revealed moderate to high risk of bias for all studies. Economic evaluation assessment identified two high-quality studies and six moderate or low quality studies. Pooled analysis from four studies assessed loss of function; loss of function decreased in the experimental arm (odds ratio 0.92, 95% confidence interval [CI]: 0.88-0.97). Pooled results for length of stay from five studies found a significant decrease (mean difference: -1.17, 95% CI: -1.63 to -0.71) after excluding the nonorthopedic trauma study. Pooled mortality was significantly decreased in seven studies (risk ratio: 0.78, 95% CI: 0.67-0.90). All studies decreased cost and improved health outcomes in a cost-effective manner. CONCLUSIONS: CGA improved return of function and mortality with reduced cost or improved utility. Our review suggests that CGA is economically dominant and the most cost-effective care model for orthogeriatric patients. Further research should examine other surgical fields.

Is current preoperative frailty assessment adequate?

SUMMARY: Preoperative frailty predicts adverse postoperative outcomes. Recommendations for preoperative assessment of elderly patients include performing a frailty assessment. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical health care professionals' perception and use of frailty assessment for perioperative care. We surveyed local health care employees to assess their attitudes toward and practices for frail patients. Nurses and allied health professionals were more likely than surgeons to agree frailty should play a role in planning a patient's care. Lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians understanding that frailty affects their patients' outcomes. Results of this survey suggest further training in frailty issues and the use of frailty assessment instruments is necessary and could improve the uptake of such tools for perioperative care planning.

Surgical frailty assessment: a missed opportunity.

BACKGROUND: Preoperative frailty predicts adverse postoperative outcomes. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical healthcare professionals' use of frailty assessment for perioperative care. METHODS: Healthcare professionals caring for patients enrolled at a Canadian teaching hospital were surveyed to assess their perceptions of frailty, as well as attitudes towards and practices for frail patients. The survey contained open-ended and 5-point Likert scale questions. Responses were compared across professions using independent sample t-tests and correlations between survey items were analyzed. RESULTS: Nurses and allied health professionals were more likely than surgeons to think frailty should play a role in planning a patient's care (nurses vs. surgeons p = 0.008, allied health vs. surgeons p = 0.014). Very few respondents (17.5%) reported that they 'always used' a frailty assessment tool. Results from qualitative data analysis identified four main barriers to frailty assessment: institutional, healthcare system, professional knowledge, and patient/family barriers. CONCLUSION: Across all disciplines, the lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians' understanding that frailty affects their patients' outcomes. Confidence in frailty assessment tool use through education and addressing barriers to implementation may increase use and improve patient care. Healthcare professionals agree that frailty assessments should play a role in perioperative care. However, few perform them in practice. Lack of knowledge about frailty is a key barrier in the use of frailty assessments and the majority of respondents agreed that they would benefit from further training.