Persistent hyperbilirubinemia following preoperative biliary stenting in patients undergoing anatomic hepatectomy predicts serious complications.

BACKGROUND: Biliary obstruction before liver resection is a known risk factor for post-operative complications. The aim of this study was to determine the impact of persistent hyperbilirubinemia following preoperative biliary drainage before liver resection. METHODS: The ACS-NSQIP (2016-2021) database was used to extract patients with cholangiocarcinoma who underwent anatomic liver resection with preoperative biliary drainage comparing those with persistent hyperbilirubinemia (> 1.2 mg/dL) to those with resolution. Patient characteristics and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including persistent hyperbilirubinemia to evaluate their independent effect on serious complications, liver failure, and mortality. RESULTS: We evaluated 463 patients with 217 (46.9%) having hyperbilirubinemia (HB) despite biliary stenting. Bivariate analysis demonstrated that patients with HB had a higher rate of serious complications than those with non-HB (80.7% vs 70.3%; P = 0.010) including bile leak (40.9% vs 31.8%; P = 0.045), liver failure (26.7% vs 17.9%; P = 0.022), and bleeding (48.4% vs 36.6%; P = 0.010). Multivariable analysis demonstrated that persistent HB was independently associated with serious complications (OR 1.88, P = 0.020) and mortality (OR 2.39, P = 0.049) but not post-operative liver failure (OR 1.65, P = 0.082). CONCLUSIONS: Failed preoperative biliary decompression is a predictive factor for post-operative complications and mortality in patients undergoing hepatectomy and may be useful for preoperative risk stratification.

Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis.

BACKGROUND: Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy. METHODS: A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test. RESULTS: A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation. CONCLUSION: Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Revisional bariatric surgery for gastroesophageal reflux disease: characterizing patient and procedural factors and 30-day outcomes for a retrospective cohort of 4412 patients.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is a well-established potential consequence of bariatric surgery and can require revisional surgery. Our understanding of the population requiring revision is limited. In this study, we aim to characterize patients requiring revisional surgery for GERD to understand their perioperative risks and identify strategies to improve their outcomes. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry, a retrospective cohort of patients who required revisional surgery for GERD in 2020 was identified. Multivariable logistic regression modelling was used to assess correlations between baseline characteristics and morbidity. RESULTS: 4412 patients required revisional surgery for GERD, encompassing 24% of all conversion procedures. In most cases, patients underwent sleeve gastrectomy (SG) as their original surgery (n = 3535, 80.1%). The revisional surgery for most patients was a Roux-en-Y gastric bypass (RYGB) (n = 3722, 84.4%). Major complications occurred in 527 patients (11.9%) and 10 patients (0.23%) died within 30 days of revisional surgery. Major complications included anastomotic leak in 31 patients (0.70%) and gastrointestinal bleeding in 38 patients (0.86%). Multivariable analyses revealed that operative length, pre-operative antacid use, and RYGB were predictors of major complications. CONCLUSION: GERD is the second most common indication for revisional surgery in patients who have undergone bariatric surgery. Patients who underwent SG as their initial procedure were the primary group who required revisional surgery for GERD; most underwent revision via RYGB. Further inquiry is needed to tailor operative approaches and pre-operative optimization for revisional surgery patients.

Attitudes of Canadian medical students towards surgical training and perceived barriers to surgical careers: a multicentre survey.

Background: Medical student interest in surgical specialties continues to decline. This study aims to characterize attitudes of Canadian medical students towards surgical training and perceived barriers to surgical careers. Methods: An anonymous survey was custom designed and distributed to medical students at the University of Alberta and University of Calgary. Survey questions characterized student interest in surgical specialties, barriers to pursuing surgery, and influence of surgical education opportunities on career interest. Results: Survey engagement was 26.7% in 2015 and 24.2% in 2021. General surgery had the highest rate of interest in both survey years (2015: 38.3%, 2021: 39.2%). The most frequently reported barrier was worry about the stress that surgical careers can put on personal relationships (2015: 70.9%, 2021: 73.8%, p= 0.50). Female respondents were significantly more likely to cite gender discrimination as a deterrent to surgical careers (F: 52.0%, M: 5.8%, p < 0.001). Conclusions: Despite substantial interest, perception of work-life imbalance was the primary reported barrier to surgical careers. Further, female medical students' awareness of gender discrimination in surgery highlights the need for continued efforts to promote gender inclusivity within surgical disciplines to support early career women interested in surgery.

Contexte: L'intérêt des étudiants en médecine canadiens pour les spécialités chirurgicales est en diminution constante. Cette étude vise à caractériser leurs attitudes à l'égard de la formation en chirurgie et les obstacles qu'ils perçoivent à la poursuite d'une carrière dans cette discipline. Méthodes: Un sondage anonyme conçu sur mesure a été distribué aux étudiants en médecine de l'Université de l'Alberta et de l'Université de Calgary. Les questions de l'enquête portaient sur leur intérêt pour les spécialités chirurgicales, sur ce qui les empêche de les choisir comme voie de carrière et sur l'influence des possibilités de formation en chirurgie sur leur intérêt à suivre une carrière dans ces spécialités. Résultats: Le taux de participation à l'enquête était de 26,7 % en 2015 et de 24,2 % en 2021. La spécialité qui a recueilli le taux d'intérêt le plus élevé était la chirurgie générale, et ce pour les deux années d'enquête (2015 : 38,3 %, 2021 : 39,2 %). L'obstacle le plus fréquemment cité était la difficile conciliation entre la vie personnelle et les exigences des carrières chirurgicales (2015 : 70,9 %, 2021 : 73,8 %, p = 0,50). Les femmes interrogées étaient significativement plus susceptibles de citer la discrimination fondée sur le sexe comme frein au choix d'une carrière chirurgicale (F : 52,0 %, M : 5,8 %, p < 0,001). Conclusions: Malgré un intérêt considérable, la perception d'un déséquilibre entre la vie professionnelle et la vie personnelle est le principal obstacle déclaré au choix d'une carrière dans le domaine de la chirurgie. De plus, la discrimination sexuelle perçue par les étudiantes dans la discipline souligne le besoin d'efforts soutenus pour promouvoir l'inclusivité des sexes dans les spécialités chirurgicales afin de soutenir les femmes en début de carrière qui s'intéressent à la chirurgie.

Mitochondrial regulation in human pluripotent stem cells during reprogramming and ß cell differentiation.

Mitochondria are the powerhouse of the cell and dynamically control fundamental biological processes including cell reprogramming, pluripotency, and lineage specification. Although remarkable progress in induced pluripotent stem cell (iPSC)-derived cell therapies has been made, very little is known about the role of mitochondria and the mechanisms involved in somatic cell reprogramming into iPSC and directed reprogramming of iPSCs in terminally differentiated cells. Reprogramming requires changes in cellular characteristics, genomic and epigenetic regulation, as well as major mitochondrial metabolic changes to sustain iPSC self-renewal, pluripotency, and proliferation. Differentiation of autologous iPSC into terminally differentiated ß-like cells requires further metabolic adaptation. Many studies have characterized these alterations in signaling pathways required for the generation and differentiation of iPSC; however, very little is known regarding the metabolic shifts that govern pluripotency transition to tissue-specific lineage differentiation. Understanding such metabolic transitions and how to modulate them is essential for the optimization of differentiation processes to ensure safe iPSC-derived cell therapies. In this review, we summarize the current understanding of mitochondrial metabolism during somatic cell reprogramming to iPSCs and the metabolic shift that occurs during directed differentiation into pancreatic ß-like cells.

AT7867 promotes pancreatic progenitor differentiation of human iPSCs.

Generation of pure pancreatic progenitor (PP) cells is critical for clinical translation of stem cell-derived islets. Herein, we performed PP differentiation with and without AKT/P70 inhibitor AT7867 and characterized the resulting cells at protein and transcript level in vitro and in vivo upon transplantation into diabetic mice. AT7867 treatment increased the percentage of PDX1+NKX6.1+ (-AT7867: 50.9% [IQR 48.9%-53.8%]; +AT7867: 90.8% [IQR 88.9%-93.7%]; p = 0.0021) and PDX1+GP2+ PP cells (-AT7867: 39.22% [IQR 36.7%-44.1%]; +AT7867: 90.0% [IQR 88.2%-93.6%]; p = 0.0021). Transcriptionally, AT7867 treatment significantly upregulated PDX1 (p = 0.0001), NKX6.1 (p = 0.0005), and GP2 (p = 0.002) expression compared with controls, while off-target markers PODXL (p < 0.0001) and TBX2 (p < 0.0001) were significantly downregulated. Transplantation of AT7867-treated PPs resulted in faster hyperglycemia reversal in diabetic mice compared with controls (time and group: p < 0.0001). Overall, our data show that AT7867 enhances PP cell differentiation leading to accelerated diabetes reversal.

Examining the equity and diversity characteristics of academic general surgeons hired in Canada.

BACKGROUND: Job competition and underemployment among surgeons emphasize the importance of equitable hiring practices. The purpose of this study was to describe some of the demographic characteristics of academic general surgeons and to evaluate the gender and visible minority (VM) status of those recently hired. METHODS: Demographic information about academic general surgeons across Canada including gender, VM status, practice location and graduate degree status was collected. Location of residency was collected for recently hired general surgeons (hired between 2013 and 2020). Descriptive statistics were performed on the demographic characteristics at each institution. Pearson correlation coefficients and hypothesis testing were used to determine the correlation between various metrics and gender and VM status. RESULTS: A total of 393 general surgeons from 30 academic hospitals affiliated with 14 universities were included. The percentage of female general surgeons ranged from 0% to 47.4% and the percentage of VM general surgeons ranged from 0% to 66.7% at the hospitals. This heterogeneity did not correlate with city population (gender: r = 0.06, p = 0.77; VM: r = 0.04, p = 0.83). The percentage of VM general surgeons at each hospital did not correlate with the percentage of VM population in the city (r = 0.13, p = 0.49). Only 34 of 120 recently hired academic general surgeons (28.3%) did not have a graduate degree. The percentage of recently hired academic general surgeons who did not have a graduate degree was approximately 1.5 times higher among male hirees than female hirees. With respect to academic promotion, the percentage of female full professors ranged from 0% to 40.0% and did not correlate with the percentage of female general surgeons at each institution (r = 0.11, p = 0.70). The percentage of VM full professors ranged from 0% to 44.4% and was moderately correlated with the percentage of VM surgeons at each institution (r = 0.40, p = 0.16). CONCLUSION: The academic general surgery workforce appears to be somewhat diverse. However, there was substantial heterogeneity in diversity between hospitals, leaving room for improvement. We must be willing to examine our hiring processes and be transparent about them to build an equitable surgical workforce.

Characterizing Canadian rural general surgeons: trends over time and 10-year replacement needs.

BACKGROUND: Recruiting residents to practise rurally begins with an accurate characterization of rural surgeons. We sought to identify and analyze demographic trends among rural surgeons in Canada and to predict the rural workforce requirements for the next decade. METHODS: In this retrospective observational study, we assessed the demographic and practice characteristics of rural general surgeons in Canada, defined as surgeons working in cities with a population of 100 000 or less. Surgeons were identified using the websites of provincial colleges of physicians and surgeons. Demographic characteristics included year and country of medical degree achievement, fellowship status and primary practice location. We developed a model predicting future rural workforce requirements based on the following assumptions: that the current ratio of rural surgeons to rural patients is adequate, that the rural population will increase by 1.1% annually, that a rural surgeon's career length is 36 years, and that 85 graduates will enter the workforce annually. RESULTS: Our study sample included 760 rural general surgeons. The majority graduated after 1989 (75%), were Canadian medical graduates (73%) and did not complete a fellowship (82%). There was a significant shift toward rural surgeons being trained in Canada, from 37% of surgeons graduating before 1969 to 91% of those graduating after 2009 (p < 0.001). Modelling predicts 282 rural general surgeons will retire by 2031, with 88 new surgeons needed to account for the population growth. Therefore, we predict a demand for 370 rural surgeons over the next decade, meaning 43% of general surgery graduates will need to enter rural practice. CONCLUSION: Rural general surgeons in Canada vary widely in their background demographic characteristics. Future opportunities in rural general surgery are projected to increase. Recruitment and training of general surgery graduates to serve Canada's rural communities remains essential.

Endoscopic plication compared to laparoscopic fundoplication in the treatment of gastroesophageal reflux disease: a systematic review and meta-analysis.

INTRODUCTION: Endoscopic plication offers an alternative to surgical fundoplication for treatment of gastroesophageal reflux disease (GERD). This systematic review and meta-analysis evaluate outcomes following endoscopic plication compared to laparoscopic fundoplication. METHODS AND PROCEDURES: Systematic search of MEDLINE, Embase, Scopus, and Web of Science was conducted in September 2022. Study followed PRISMA guidelines. Studies comparing endoscopic plication to laparoscopic fundoplication with n > 5 were included. Primary outcome was PPI cessation, with secondary outcomes including complications, procedure duration, length of stay, change in lower esophageal sphincter (LES) tone, and DeMeester score. RESULTS: We reviewed 1544 studies, with five included comparing 105 (46.1%) patients receiving endoscopic plication (ENDO) to 123 (53.9%) undergoing laparoscopic fundoplication (LAP). Average patient age was 47.6 years, with those undergoing plication being younger (46.4 ENDO vs 48.5 LAP). BMI (26.6 kg/m2 ENDO vs 26.2 kg/m2 LAP), and proportion of females (42.9% ENDO vs 37.4% LAP) were similar. Patients undergoing laparoscopic procedures had worse baseline LES pressure (12.8 mmHg ENDO vs 9.0 mmHg LAP) and lower preoperative DeMeester scores (34.6 ENDO vs. 34.1 LAP). The primary outcome demonstrated that 89.2% of patients undergoing laparoscopic fundoplication discontinued PPI compared to 69.4% for those receiving plication. Meta-analysis revealed that plication had significantly reduced odds of PPI discontinuation (OR 0.27, studies = 3, 95% CI 0.12 to 0.64, P = 0.003, I2 = 0%). Secondary outcomes demonstrated that odds of complications (OR 1.46, studies = 4, 95% CI 0.34 to 6.32, P = 0.62, I2 = 0%), length of stay (MD - 1.37, studies = 3, 95% CI - 3.48 to 0.73, P = 0.20, I2 = 94%), and procedure durations were similar (MD 0.78, studies = 3, 95% CI - 39.70 to 41.26, P = 0.97, I2 = 98%). CONCLUSIONS: This is the first meta-analysis comparing endoscopic plication to laparoscopic fundoplication. Results demonstrate greater likelihood of PPI discontinuation with laparoscopic fundoplication with similar post-procedural risk.

MBSAQIP risk calculator use in bariatric surgery is associated with a reduction in serious complications: a retrospective analysis of 210,710 patients.

BACKGROUND: The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) Bariatric Surgical Risk/Benefit Calculator was developed to provide patient-specific information to assist surgical decision-making. To date, no study has characterized which patients are being evaluated with this tool. OBJECTIVE: We sought to characterize the use and impact of the MBSAQIP calculator. SETTING: MBSAQIP collects data from 955 centers in North America. METHODS: The 2021 MBSAQIP database was evaluated for the use of the calculator on preoperative counseling for patients undergoing bariatric surgery. Patient characteristics, operative techniques, and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including use of the calculator independently associated with serious complications and mortality. RESULTS: Our study included 210,710 patients, 35,158 (16.7%) of whom were evaluated using the calculator. Patients with whom the calculator was used preoperatively were older (43.8 ± 11.6 yr versus 43.6 ± 11.7 yr; P < .001) and were more likely to have insulin-dependent diabetes, hypertension, gastroesophageal reflux disease, renal insufficiency, and sleep apnea. More patients underwent Roux-en-Y gastric bypass in the calculator cohort compared with the cohort that did not use the calculator (29.6% versus 28.6%; P < .003). The rate of serious complication was significantly less in the calculator cohort (3.1% versus 3.4%; P < .030). Multivariable modeling evaluating serious complications showed that use of the calculator was independently associated with reduced risk of serious complications (odds ratio .87, CI .82-.93, P < .001) but was not associated with mortality. CONCLUSION: The use of the risk calculator may help to reduce the incidence of complications by opening a dialogue between healthcare professionals and patients, setting realistic expectations, and identifying modifiable risk factors.

Suspension culture improves iPSC expansion and pluripotency phenotype.

BACKGROUND: Induced pluripotent stem cells (iPSCs) offer potential to revolutionize regenerative medicine as a renewable source for islets, dopaminergic neurons, retinal cells, and cardiomyocytes. However, translation of these regenerative cell therapies requires cost-efficient mass manufacturing of high-quality human iPSCs. This study presents an improved three-dimensional Vertical-Wheel® bioreactor (3D suspension) cell expansion protocol with comparison to a two-dimensional (2D planar) protocol. METHODS: Sendai virus transfection of human peripheral blood mononuclear cells was used to establish mycoplasma and virus free iPSC lines without common genetic duplications or deletions. iPSCs were then expanded under 2D planar and 3D suspension culture conditions. We comparatively evaluated cell expansion capacity, genetic integrity, pluripotency phenotype, and in vitro and in vivo pluripotency potential of iPSCs. RESULTS: Expansion of iPSCs using Vertical-Wheel® bioreactors achieved 93.8-fold (IQR 30.2) growth compared to 19.1 (IQR 4.0) in 2D (p < 0.0022), the largest expansion potential reported to date over 5 days. 0.5 L Vertical-Wheel® bioreactors achieved similar expansion and further reduced iPSC production cost. 3D suspension expanded cells had increased proliferation, measured as Ki67+ expression using flow cytometry (3D: 69.4% [IQR 5.5%] vs. 2D: 57.4% [IQR 10.9%], p = 0.0022), and had a higher frequency of pluripotency marker (Oct4+Nanog+Sox2+) expression (3D: 94.3 [IQR 1.4] vs. 2D: 52.5% [IQR 5.6], p = 0.0079). q-PCR genetic analysis demonstrated a lack of duplications or deletions at the 8 most commonly mutated regions within iPSC lines after long-term passaging (> 25). 2D-cultured cells displayed a primed pluripotency phenotype, which transitioned to naïve after 3D-culture. Both 2D and 3D cells were capable of trilineage differentiation and following teratoma, 2D-expanded cells generated predominantly solid teratomas, while 3D-expanded cells produced more mature and predominantly cystic teratomas with lower Ki67+ expression within teratomas (3D: 16.7% [IQR 3.2%] vs.. 2D: 45.3% [IQR 3.0%], p = 0.002) in keeping with a naïve phenotype. CONCLUSION: This study demonstrates nearly 100-fold iPSC expansion over 5-days using our 3D suspension culture protocol in Vertical-Wheel® bioreactors, the largest cell growth reported to date. 3D expanded cells showed enhanced in vitro and in vivo pluripotency phenotype that may support more efficient scale-up strategies and safer clinical implementation.

Duodenal-jejunal bypass liners are superior to optimal medical management in ameliorating metabolic dysfunction: A systematic review and meta-analysis.

This systematic review and meta-analysis evaluates metabolic and anthropometric outcomes of duodenal-jejunal bypass liners (DJBLs) compared to optimal medical management for the treatment of obesity and its associated metabolic complications. A systematic search of MEDLINE, Embase, Scopus, and Web of Science databases was conducted. Studies were reviewed and data were extracted following the PRISMA guidelines. The primary outcome was glycated hemoglobin (HbA1c) change at device explant with secondary outcomes including body mass index (BMI), weight, fasting plasma glucose (FPG), and adverse events. Twenty-eight studies met inclusion criteria evaluating a total of 1229 patients undergoing DJBL treatment. When compared to medical management, DJBLs provided superior reductions in HbA1c (mean difference, MD -0.96%; 95% CI -1.43, -0.49; p < 0.0001), FPG (MD -1.76 mmol/L; 95% CI -2.80, -0.72; p = 0.0009), BMI (MD -2.80 kg/m2 ; 95% CI -4.18, -1.41; p < 0.0001), and weight (MD -5.45 kg; 95% CI -9.80, -1.09, p = 0.01). Post-explant data reveals a gradual return to baseline status. Incidence of early device explant was 20.2%. Complications were resolved conservatively or with device explant without long-term morbidity or mortality. We conclude that DJBLs provide significant metabolic and anthropometric improvements for patients with obesity. Uncertainty about the extent to which improvements are maintained after device removal may limit the use of DJBLs as a standalone treatment for obesity and associated metabolic complications.

Oral care reduces incidence of pneumonia after esophagectomy: systematic review and meta-analysis.

PURPOSE: Post-operative pneumonia after esophagectomy is a major contributor to morbidity and mortality. Prior studies have demonstrated a link between the presence of pathologic oral flora and the development of aspiration pneumonia. The objective of this systematic review and meta-analysis was to evaluate the effect of pre-operative oral care on the incidence of post-operative pneumonia after esophagectomy. METHODS: A systematic search of the literature was performed on September 2, 2022. Screening of titles and abstracts, full-text articles, and evaluation of methodological quality was performed by two authors. Case reports, conference proceedings, and animal studies were excluded. A meta-analysis of peri-operative oral care on the odds of post-operative pneumonia after esophagectomy was performed using Revman 5.4.1 with a Mantel-Haenszel, random-effects model. RESULTS: A total of 736 records underwent title and abstract screening, leading to 28 full-text studies evaluated for eligibility. A total of nine studies met the inclusion criteria and underwent meta-analysis. Meta-analysis revealed a significant reduction in post-operative pneumonia among patients undergoing pre-operative oral care intervention compared to those without an oral care intervention (OR 0.57, 95% CI 0.43-0.74, p < 0.0001; I2 = 49%). CONCLUSION: Pre-operative oral care interventions have significant potential in the reduction of post-operative pneumonia after esophagectomy. North American prospective studies, as well as studies on the cost-benefit analysis, are required.

Paramedic to trauma team verbal handover optimization - a complex interaction.

BACKGROUND: Handover to the trauma team is crucial to trauma care. The emergency medical services (EMS) report must be concise, contain key details, and be time-limited. Effective handover is difficult, often occurring between unfamiliar teams, in chaotic environments, and without standardization. We aimed to evaluate handover formats in comparison to ad-lib communication during trauma handover. METHODS: We conducted a single-blind randomized simulation trial evaluating 2 structured handover formats. Paramedics randomly assigned to ad-lib, ISOBAR (identify, situation, observations, background, agreed plan, and readback) or IMIST (identification, mechanism/medical complaint, injuries/ information about complaint, signs, treatments) handover formats underwent scenarios in an ambulance, then transfer to the trauma team. Assessment of handovers was completed by the trauma team and by experts using audiovisual recordings. RESULTS: Twenty-seven simulations were conducted, 9 for each handover format. Participant ratings of the usefulness of the IMIST and ISOBAR formats were 9/10 and 7.5/10, respectively (p = 0.097). Quality of the handover was deemed higher by team members when a statement of objective vital signs and a logical format was used. Handovers delivered with confidence, directed and summarized by a trauma team leader, before physical patient transfer, and without interruption were identified as having the highest quality. The type of format was not a significant contributor to handover; however, we identified a matrix of factors affecting the quality of trauma handover. CONCLUSION: Our study shows agreement by prehospital and hospital personnel that a standardized handover tool is preferred. A brief confirmation of physiologic stability, including vital signs, limiting distractions, and team summarization improves handover effectiveness.

Stem Cell-Derived Islet Transplantation in Patients With Type 2 Diabetes: Can Diabetes Subtypes Guide Implementation?

Historically, only patients with brittle diabetes or severe recurrent hypoglycemia have been considered for islet transplantation (ITx). This population has been selected to optimize the risk-benefit profile, considering risks of long-term immunosuppression and limited organ supply. However, with the advent of stem cell (SC)-derived ITx and the potential for immunosuppression-free ITx, consideration of a broader recipient cohort may soon be justified. Simultaneously, the classical categorization of diabetes is being challenged by growing evidence in support of a clustering of disease subtypes that can be better categorized by the All New Diabetics in Scania (ANDIS) classification system. Using the ANDIS classification, 5 subtypes of diabetes have been described, each with unique causes and consequences. We evaluate consideration for ITx in the context of this broader patient population and the new classification of diabetes subtypes. In this review, we evaluate considerations for ITx based on novel diabetes subtypes, including their limitations, and we elaborate on unique transplant features that should now be considered to enable ITx in these "unconventional" patient cohorts. Based on evidence from those receiving whole pancreas transplant and our more than 20-year experience with ITx, we offer recommendations and potential research avenues to justify implementation of SC-derived ITx in broader populations of patients with all types of diabetes.

Multicentre Analysis of Cost, Uptake and Safety of Canadian Multidisciplinary Pancreatic Cyst Guidelines.

Background: Pancreatic cystic lesions (PCLs) are common, with several guidelines providing surveillance recommendations. The Canadian Association of Radiologists published surveillance guidelines (CARGs) intended to provide simplified, cost-effective and safe recommendations. This study aimed to evaluate cost savings of CARGs compared to other North American guidelines including American Gastroenterology Association guidelines (AGAG) and American College of Radiology guidelines (ACRG), and to evaluate CARG safety and uptake. Methods: This is a multicentre retrospective study evaluating adults with PCL from a single health zone. MRIs completed from September 2018-2019, one year after local CARG guideline implementation, were reviewed to identify PCLs. All imaging following 3-4 years of CARG implementation was reviewed to evaluate true costs, missed malignancy and guideline uptake. Modelling, including MRI and consultation, predicted and compared costs associated with surveillance based on CARGs, AGAGs and ACRGs. Results: 6698 abdominal MRIs were reviewed with 1001 (14.9%) identifying PCL. Application of CARGs over 3.1 years demonstrated a >70% cost reduction compared to other guidelines. Similarly, the modelled cost of surveillance for 10-years for each guideline was $516,183, $1,908,425 and $1,924,607 for CARGs, AGAGs and ACRGs respectively. Of patients suggested to not require further surveillance per CARGs, approximately 1% develop malignancy with fewer being candidates for surgical resection. Overall, 44.8% of initial PCL reports provided CARG recommendations while 54.3% of PCLs were followed as per CARGs. Conclusions: CARGs are safe and offer substantial cost and opportunity savings for PCL surveillance. These findings support Canada-wide implementation with close monitoring of consultation requirements and missed diagnoses.

Long-term outcomes after normothermic machine perfusion in liver transplantation-Experience at a single North American center.

Normothermic machine perfusion (NMP) has emerged as a valuable tool in the preservation of liver allografts before transplantation. Randomized trials have shown that replacing static cold storage (SCS) with NMP reduces allograft injury and improves graft utilization. The University of Alberta's liver transplant program was one of the early adopters of NMP in North America. Herein, we describe our 7-year experience applying NMP to extend preservation time in liver transplantation using a "back-to-base" approach. From 2015 to 2021, 79 livers were transplanted following NMP, compared with 386 after SCS only. NMP livers were preserved for a median time of minutes compared with minutes in the SCS cohort (P < .0001). Despite this, we observed significantly improved 30-day graft survival (P = .030), although there were no differences in long-term patient survival, major complications, or biliary or vascular complications. We also found that although SCS time was strongly associated with increased graft failure at 1 year in the SCS cohort (P = .006), there was no such association among NMP livers (P = .171). Our experience suggests that NMP can safely extend the total preservation time of liver allografts without increasing complications.

A 5-year characterization of trends and outcomes in elderly patients undergoing elective bariatric surgery.

BACKGROUND: The North American population with severe obesity is aging and with that so will the number of elderly patients (≥ 65 years) meeting indications for metabolic surgery. Trends in bariatric delivery in this population are poorly characterized and outcomes remain conflicting, limiting potential uptake and delivery. METHODS: The MBSAQIP database was used to identify elderly patients (≥ 65 years) undergoing elective bariatric surgery from 2015 to 2019. Our objectives were to analyze their unique characteristics, surgical operative trends, and outcomes by comparing to a non-elderly cohort. Multivariable logistic regression identified independent predictors of serious complications and 30-day mortality. RESULTS: There was a total of 751,607 patients, 5.3% (n = 39,854) were elderly. Mean ages were 43 ± 11 years (non-elderly) versus 68 ± 3 years (elderly). Elderly patients were less likely to be female (70.7% elderly; 80.1% non-elderly) and had lower BMI (43.17 ± 6.64 kg/m2 elderly; 45.42 ± 7.87 kg/m2 non-elderly). They had higher American Society of Anesthesiologists classification, lower functional status, more insulin dependent diabetes, and hypertension, among other comorbidities. There were no clinically significant differences between the most frequently performed bariatric surgery. Sleeve gastrectomy remained the most common (73.7% non-elderly; 72.3% elderly); however, operative time was longer among the elderly. Functional status was most predictive for both serious complications (OR 1.72; CI 1.53-1.94) and mortality (OR 2.92; CI 1.98-4.31). Surgery among elderly patients was associated with poorer 30-day postoperative outcomes across all categories and was independently associated with serious complications (OR 1.23; CI 1.17-1.30, p < 0.001; AR 4.64%) and 30-day mortality (OR 2.49; CI 2.00-3.11, p < 0.001; AR 0.27%), after adjusting for comorbidities. CONCLUSIONS: After adjusting for comorbidities, functional status remains the most predictive factor for poor outcomes; however, elderly patients have increased 30-day odds of serious complications and 30-day mortality, suggesting a need to tailor our approach to these individuals that carry a unique operative risk.

Characteristics and outcomes for patients undergoing revisional bariatric surgery due to persistent obesity: a retrospective cohort study of 10,589 patients.

BACKGROUND: Revisional bariatric surgery in an option for patients who experience weight regain or inadequate weight loss after primary elective bariatric procedures. However, there is conflicting data on safety outcomes of revisional procedures. We aim to characterize patient demographics, procedure type, and safety outcomes for those undergoing revisional compared to initial bariatric interventions to guide management of these patients. METHODS: The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing primary elective to revisional bariatric procedures for inadequate weight loss. Bivariate analysis was performed to determine between group differences. Multivariable logistic regression determined factors associated with serious complications or mortality. RESULTS: We evaluated 158,424 patients, including 10,589 (6.7%) revisional procedures. Patients undergoing revisional procedures were more like to be female (85.5% revisional vs. 81.0% initial; p < 0.001), had lower body mass index (43.6 ± 7.8 kg/m2 revisional vs. 45.2 ± 7.8 kg/m2 initial; p < 0.001), and less metabolic comorbidities than patients undergoing primary bariatric surgery. The most common revisional procedures were Roux-en-Y gastric bypass (48.4%) and sleeve gastrectomy (32.5%). Revisional procedures had longer operative duration compared to primary procedures. Patients undergoing revisional procedures were more likely to experience readmission to hospital (4.8% revisional vs. 2.9% initial; p < 0.001) and require reoperation (2.4% revisional vs. 1.0% initial; p < 0.001) within 30 days of the procedure. Revisional procedures were independently associated with increased serious complications (OR 1.49, CI 1.36-1.64, p < 0.001) but were not a significant predictor of 30-day mortality (OR 0.74, CI 0.36-1.50, p = 0.409). CONCLUSIONS: In comparison to primary bariatric surgery, patients undergoing revisional procedures have less metabolic comorbidities. Revisional procedures have worse perioperative outcomes and are independently associated with serious complications. These data help to contextualize outcomes for patients undergoing revisional bariatric procedures and to inform decision making in these patients.