Venous thromboembolic prophylaxis: current practice of surgeons in Australia and New Zealand for major abdominal surgery.

BACKGROUND: Surgical prophylaxis for venous thrombo-embolic disease (VTE) includes risk assessment, chemical prophylaxis and mechanical prophylaxis (graduated compression stockings [GCS] and/or intermittent pneumatic compression devices [IPCD]). Although there is overwhelming evidence for the need and efficacy of VTE prophylaxis in patients at risk, only about a third of those who are at risk of VTE receive appropriate prophylaxis. OBJECTIVE: There is debate as to the best combination of VTE prophylaxis following abdominal surgery due to lack of evidence. The aim of this survey was to understand this gap between knowledge and practice. METHODS: In 2019 and 2020, a survey was conducted to investigate the current practice of venous thromboembolism (VTE) prophylaxis for major abdominal surgery, with a focus on colorectal resections. The study received ethics approval and involved distributing an 11-item questionnaire to members of two professional surgical societies: the Colorectal Surgical Society of Australia and New Zealand (CSSANZ) and the General Surgeons Australia (GSA). RESULTS: From 214 surgeons: 100% use chemical prophylaxis, 68% do not use a risk assessment tool, 27% do not vary practice according to patient risk factors while > 90% use all three forms of VTE prophylaxis at some stage of treatment. Most surgeons do not vary practice between laparoscopic and open colectomy/major abdominal surgery and only 33% prescribe post-discharge chemical prophylaxis. 42% of surgeons surveyed had equipoise for a clinical trial on the use of IPCDs and the vast majority (> 95%) feel that IPCDs should provide at least a 2% improvement in VTE event rate in order to justify their routine use. CONCLUSION: Most surgeons in Australia and New Zealand do not use risk assessment tools and use all three forms of prophylaxis regardless. Therfore there is a gap between practice and VTE prophylaxis for the use of mechanical prophylaxis options. Further research is required to determine whether dual modality mechanical prophylaxis is incrementally efficacious. Trial Registration- Not Applicable.

Attitudes Affecting Decision-Making for Use of Radiologic Enteral Contrast in the Management of Pediatric Adhesive Small Bowel Obstruction: A Survey Study of Pediatric Surgeons.

BACKGROUND: Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO. METHODS: We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium. RESULTS: The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence. CONCLUSIONS: Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.

Patient Satisfaction With Decision Making Does Not Correlate With Patient Centeredness of Surgeons.

BACKGROUND: High-quality decision making is important in patient-centered care. Although patient involvement in decision making varies widely, most patients desire to share in decision making. The Press-Ganey Patient Satisfaction survey includes questions that measure patients' perceptions of their providers' efforts to involve them in decision making (PGDM). We hypothesized that higher PGDM scores would correlate with higher scores on a validated measure of patient centeredness. MATERIALS AND METHODS: Surgical providers at a university hospital who routinely receive Press-Ganey scores received a survey that included the Patient-Practitioner Orientation Scale (PPOS), a validated tool that measures the provider's orientation toward patient centeredness on a continuous six-point scale: score ≥5 = high, 4.57-5 = moderate, and <4.57 = low and includes nine-item "caring" or "sharing" subscales. We compared PPOS scores to PGDM scores, averaged from April 2015 to January 2016. RESULTS: Eighty-six of 112 (75%) of surgical providers responded to the survey. Fifty-two (46%) had PGDM scores available and 26% achieved a perfect score on the PGDM. The overall PPOS scores were low, with a mean of 4.2 (SD = 0.5). The PPOS was not correlated with the PGDM, correlation coefficient (rs) = -0.07 (CI: -0.34-0.21, P = 0.63). Similarly, the two subscales of the PPOS did not correlate with the PGDM with rs = -0.15 (CI: -0.41-0.13, P = 0.29) for "caring" and rs = -0.04 (CI: -0.31-0.23, P = 0.76) for "sharing". CONCLUSIONS: Although surgical providers scored low in patient centeredness using the PPOS, over one-quarter (26%) of them rank in the top 1% on the PGDM. No correlation was found between providers' patient centeredness and their patients' perceptions of efforts to include them in decision making.

Bariatric surgeons' views on pre-operative factors associated with improved health-related quality of life following surgery.

Bariatric surgery is an effective treatment for severe obesity, affording significant improvements in weight loss and health-related quality of life. However, bariatric surgeons' views on whether certain pre-operative factors predict improvements in post-operative health-related quality of life, and if so, which ones, are largely unknown. This cross-sectional survey study examined the views of 58 bariatric surgeons from Australia and New Zealand. A total of 18 factors were selected for exploration based on their mention in the literature. Participants rated the extent to which they thought these pre-operative factors would improve post-operative health-related quality of life. Responses showed that bariatric surgeons held diverse perspectives and revealed a lack of consensus regarding "predictive" factors. Generally, respondents agreed that better than average health literacy, higher socioeconomic status, good physical and psychological health, and positive social support were predictors of improved health-related quality of life following surgery. However, poor eating behaviours, smoking, and the use of alcohol or other substances were deemed negative predictors. Interestingly, aside from higher socioeconomic status, good psychological health, and positive social support, none of the aforementioned views aligned with existing literature. This study offers an initial insight into bariatric surgeons' views on the influence of different pre-operative factors on post-operative health-related quality of life. The array of views identified suggests that there may be an opportunity for medical education, but the findings warrant caution due to the sample size. Replication with a larger survey may be useful, especially as predicted health-related quality of life outcomes could guide decisions regarding surgical (non)progression.

Surgeon perceptions of volume threshold and essential practices for pediatric thyroidectomy✰.

INTRODUCTION: The topics of sub-specialization and regionalization of care have garnered increased attention among pediatric surgeons. Thyroid surgeries are one such sub-specialty and are commonly concentrated within practices. A national survey was conducted examining current surgeon practices and beliefs surrounding pediatric thyroid surgery. METHODS: Non-resident members of the American Pediatric Surgical Association (APSA) were surveyed in October 2020. Respondents were stratified based on self-reported thyroid surgical experience. Those who performed thyroid surgery were asked about surgical technique and operative practices; those who did not were asked about referral patterns. All respondents were asked about perceptions surrounding the volume-outcome relationship for pediatric thyroid surgery. RESULTS: Among 1015 APSA members, 405 (40%) responded, with 79% (317/400) practicing at academic hospitals, 58% (232/401) practicing in major metropolitan area, and 41% (161/392) with over 10 years of attending pediatric surgery experience. Most respondents (88%, n = 356) agreed that thyroid surgery volume affects outcome, though wide variation was reported in the annual case threshold for "high volume" surgery. Eighty-four respondents (21%) reported performing ≥ 1 pediatric thyroid surgery in the past year. Of these, 82% routinely use recurrent laryngeal nerve monitoring, 32% routinely send hemithyroidectomy patients home the same day, and there was little consensus surrounding postoperative hypocalcemia management. The majority of respondents endorse performing thyroid procedures with a colleague. CONCLUSIONS: Pediatric thyroid surgery appears to be performed by a subset of active pediatric surgeons, most of whom endorse the use of a dual operating team. More evidence is needed to build consensus around additional perioperative practices.

(FLiP) fracture-table vs. lateral positioning for femoral intramedullary nailing: A survey of orthopaedic surgeon preferences.

BACKGROUND: Femoral shaft fractures are common and severe injuries that often occur alongside other complex, high-energy injuries. Definitive internal fixation using reamed, locked intramedullary nailing (IMN) has become the standard of care in adequately resuscitated patients, commonly performed in the supine position with utilization of a fracture table. The lateral position, without the use of traction, offers an alternative that may be associated with lower complication rates. Given the lack of high-quality evidence in the area, this study was designed to assess the attitudes, knowledge base and preferences of Orthopaedic surgeons regarding patient positioning during antegrade IMN of femoral shaft fractures. METHODS: Orthopedic surgeon members of the AO North America, Canadian Orthopaedic Association and the Ontario Orthopaedic Association were invited to participate in a web-based survey addressing the management of femoral shaft fractures and the need for further research in this area. RESULTS: Most surgeons (56%) favored treating mid-shaft femur fractures in the supine position using a fracture table compared to supine/sloppy lateral (29%) or direct lateral (12%) with the leg free draped. Canadian surgeons showed a significantly higher preference for supine positioning with a fracture table when compared to their American colleagues. Academic and higher-level trauma center surgeons were more likely to prefer the sloppy lateral or direct lateral positioning with manual traction compared to community surgeons. The most commonly cited perceived barrier for utilizing the lateral position was expertise and lack of available assistants. Forty-five percent of respondents expressed interest in being involved in a randomized control trial comparing lateral positioning vs. supine with traction. CONCLUSION: Consensus surrounding the positioning and utilization of traction in femoral shaft fractures is lacking. Given the perceived possible benefits and reduced complications using the lateral position and free-leg draping, further research is warranted to determine the optimal positioning for these injuries during femoral IMN. LEVEL OF EVIDENCE: IV STUDY TYPE: Cross-sectional Survey.

Surgeon Survey Shows No Adverse Events With MRI in Patients With Magnetically Controlled Growing Rods (MCGRs).

STUDY DESIGN: Surgeon survey. OBJECTIVES: To determine if magnetic resonance imaging (MRI) following implantation of magnetically controlled growing rods (MCGRs) is associated with any adverse events. SUMMARY OF BACKGROUND DATA: Magnetically controlled growing rods have been shown to reduce the need for repeated surgical procedures and improve costs when compared to traditional growing rods, but concerns about MRI compatibility exist. MRIs are often clinically indicated in the EOS population. METHODS: Pediatric spine surgeons who are members of the Growing Spine Study Group, Children's Spine Study Group, and early international users of this technology were surveyed regarding MRI use after performing MCGR surgery. RESULTS: A total of 118 surgeons were surveyed. Four surgeons reported that 10 patients had an MRI with an implanted MCGR. Loss of fixation (0%, 0/10), movement of implants (0%, 0/10), unintended lengthening/shortening (0%, 0/10), or noticeable heating of MCGR (0%, 0/10) were not observed. No problems were observed with function of the MCGR following MRI, and a mean of 2.1 mm was obtained at the next lengthening (range, 0.5-3.0 mm). Two patients had brain MRIs, both of which could be interpreted. All cervical spine MRIs could be interpreted without excessive artifact (100%, 7/7). Six patients had MRIs of the thoracic or lumbar spine, but these were considered uninterpretable as a result of artifact from the MCGR device (0%, 0/6). CONCLUSION: These are the first reported cases of MRI use in humans with MCGR. There were no adverse events observed. MCGR rods lengthened as expected following MRI. MRIs of the brain and cervical spine were able to be interpreted, but MRIs of the thoracolumbar spine could not be interpreted because of MCGR artifact. MRIs can be safely performed in patients with MCGRs; however, MRIs of thoracic and thoracolumbar spine may be of limited clinical benefit because of artifact. LEVEL OF EVIDENCE: Level IV, case series.

Postoperative Assessment of Pedicle Screws and Management of Breaches: A Survey among Canadian Spine Surgeons and a New Scoring System.

STUDY DESIGN: This study was designed as a survey amongst Canadian spine surgeon to determine a scoring system to standardize pedicle screw placement assessment. PURPOSE: This study aimed to obtain and analyze the opinions of spine surgeons regarding the assessment of pedicle screw accuracy, with the goal of establishing clinical guidelines for interventions for malpositioned pedicle screws. OVERVIEW OF LITERATURE: Accurate placement of pedicle screws is challenging, and misalignment can lead to various complications. To date, there is no recognized gold standard for assessing pedicle screw placement accuracy. The literature is lacking studies attempting to standardize pedicle screw placement accuracy assessment. METHODS: A survey of the clinical methods and imaging criteria that are used for assessing pedicle screw placement accuracy was designed and sent to orthopedic and neurosurgery spine surgeons from the Canadian Spine Society for their anonymous participation. RESULTS: Thirty-five surgeons completed the questionnaire. The most commonly used modalities for assessing pedicle screw position postoperatively were plain X-rays (97%) and computed tomography (CT, 97%). In both symptomatic and asymptomatic patients, the most and least worrisome breaches were medial and anterior breaches, respectively. The majority of surgeons tended not to re-operate on asymptomatic breaches. More than 60% of surgeons would re-operate on patients with new-onset pain and a ≤4-mm medial or inferior breach in both thoracic and lumbar regions. If a patient experienced sensory loss and a breach on CT, in either the thoracic or lumbar levels, 90% and 70% of the surgeons would re-operate for a medial breach and an inferior breach, respectively. CONCLUSIONS: Postoperative clinical presentation and imaging findings are crucial for interpreting aberrant pedicle screw placement. This study presents a preliminary scoring system for standardizing the classification of pedicle screws.