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.

Timing of cholecystectomy following endoscopic sphincterotomy: a population-based study.

BACKGROUND: Choledocholithiasis is commonly treated initially with endoscopic sphincterotomy, followed by cholecystectomy to definitively address the underlying problem of cholelithiasis. While the benefits of early cholecystectomy have been realized in other populations, the preferred timing for this subset of patients is less well established. We performed a large, population-based analysis to determine the frequency, benefits, and practice variance in regard to early cholecystectomy on a provincial level. METHODS: Patients undergoing endoscopic sphincterotomy followed by cholecystectomy in British Columbia, Canada, from January 2001 to December 2011 were identified using fee-code billing data. Multiple databases were linked to obtain information on demographics, admissions, procedures, mortality, and census geographic data. Regression analysis was performed for length of stay (LOS) and additional procedures. Outcome data were risk adjusted for age, gender, comorbidities, socioeconomic status, and year of procedure. Variability of early cholecystectomy crude rates across census areas was determined using a funnel plot. RESULTS: There were 4287 eligible patients. Of these, 1905 (44.4%) underwent early cholecystectomy, defined as surgery within 14 days of sphincterotomy. Median interval to cholecystectomy was 2 days for the early cholecystectomy group and 61 days for delayed. There was a significant difference in hospital LOS favoring early cholecystectomy for patients with documented gallstone disease (p < 0.05). Patients initially admitted to a surgical service were more likely to undergo early cholecystectomy (60 vs. 36%, p < 0.001). There was no difference between groups in terms of bile duct injury or mortality. There was wide variability in rates of early cholecystectomy among census areas (range 0-96%) and health regions (range 20-66%) which was not explained by population density or geography. CONCLUSION: Early cholecystectomy is the ideal approach to gallstone disease post-sphincterotomy. Despite this, a large amount of clinical variance exists in regard to timing of cholecystectomy which seems to be primarily institution dependent.

Early versus delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis.

BACKGROUND: The recommended treatment for patients presenting with mild acute biliary pancreatitis is early cholecystectomy performed during the index admission. However, the data are less clear in regards to patients who undergo endoscopic sphincterotomy prior to surgery. While it has been shown that these patients still benefit from cholecystectomy, the optimal timing of this intervention is not well defined. We hypothesized that delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis is associated with significant preventable morbidity. METHODS: A retrospective chart review was performed at two academic hospitals for patients diagnosed with biliary pancreatitis who underwent endoscopic sphincterotomy followed by cholecystectomy. Patients aged 18 and over admitted from 2006 to 2011 were included, while those with severe pancreatitis were excluded. The primary outcome was biliary complications experienced during the waiting period for cholecystectomy. Secondary outcomes included length of stay, operative complications, and conversion rate. Student t test was used to compare continuous data and Fischer's exact test was used for categorical data. RESULTS: 80 patient charts were reviewed. Time to cholecystectomy was 3.3 days (range 0.5-10) in the early group and 141.6 (range 18-757) in the delayed group. The groups were comparable in terms of age and American Society of Anesthesiologists (ASA) classification. 21 of 35 patients (60%) in the delayed group experienced biliary complications compared with 1 of 45 (2%) in the early group (p < 0.001). 14 patients in the delayed group required re-admission (40%) and 5 (14%) required additional procedures. Secondary outcomes were not statistically significant. CONCLUSIONS: The data demonstrate a significantly increased biliary complication rate associated with delayed cholecystectomy in this patient population. Early cholecystectomy should be strongly considered for patients with mild biliary pancreatitis even when endoscopic sphincterotomy has been performed pre-operatively.

Bowel obstruction following appendectomy: what is the true incidence?

INTRODUCTION: Appendicitis is a common problem that is typically treated with an appendectomy. Following abdominal surgery, adhesions may form and may cause a subsequent small bowel obstruction (SBO). The purpose of our study was to determine the rate of post-appendectomy SBO in an adult population, and to observe any difference in SBO rates between open versus laparoscopic appendectomies. METHODS: All patients who underwent an appendectomy at an adult hospital in the Calgary Health Region between 1999 and 2002 were identified by using the administrative discharge database. Pathology and operative technique (laparoscopic, McBurney incision, midline laparotomy) were reviewed. Using those regional health numbers, any further admissions with a diagnostic code for bowel obstruction were identified. Medical charts (n = 1777) were reviewed to confirm the rate of post-appendectomy SBO. A logistic regression was performed to identify risk factors of post-appendectomy SBO and expressed as odds ratios (95% confidence interval). RESULTS: The overall SBO rate was 2.8% over an average 4.1-year follow-up period. The risk factors for developing SBO following appendectomy for appendicitis included, perforated appendicitis (odds ratio [OR] = 3.1, 95% confidence interval [CI]: 1.5-6.6), and midline incisions (OR = 5.4, 95% CI: 2.8-10.4). Those with pathology of cancer or chronic appendicitis conferred the greatest overall risk of SBO (OR = 7.4, 95% CI: 2.7-20.3). CONCLUSIONS: The rate of SBO following appendectomy in adults was 2.8%, or 0.0069 cases per person-year. The greatest risk factors for developing SBO were midline incision and nonappendicitis pathology. There is no statistically significant difference in SBO rates following laparoscopic appendectomy compared with open approaches.