PReoperative very low-Energy diets for obese PAtients undergoing non-bariatric surgery Randomized Evaluation (PREPARE): a protocol for a pilot randomized controlled trial.

BACKGROUND: Patients with obesity presenting in need of surgical intervention are at 2-to-sixfold higher risk of prolonged hospitalization, infectious morbidity, venous thromboembolism, and more. To mitigate some of these concerns, prescribed preoperative weight loss via very low-energy diets (VLEDs) has become a standard of care for patients with obesity undergoing bariatric surgery. While VLEDs have become standard prior to bariatric surgery, their application in other surgical settings remains limited. A large, definitive trial is required to resolve the uncertainty surrounding their use in these patients. Prior to a definitive trial to compare the efficacy of VLEDs in patients with obesity undergoing major non-bariatric surgery, we require a pilot trial. We argue a pilot trial will provide the following critical feasibility insights: (1) assessment of recruitment ability, (2) evaluation of adherence to VLED regimens, and (3) assessment of our ability follow patients completely. METHODS: The proposed trial will be a multi-center, surgeon, outcome assessor, and data-analyst blinded, parallel pilot randomized controlled trial (RCT). Patients older than 18 years of age with a body mass index (BMI) of greater than 30 kg/m2 undergoing major elective non-bariatric surgery will be eligible for inclusion. Consecutive patients will be allocated 1:1 according to a computer-generated randomization schedule. Randomization will be stratified by center and will employ randomly permutated blocks. All patients in the intervention group will receive standard patient counseling on weight loss and an active VLED protocol. The preoperative VLED protocol will utilize commercially available weight loss products for three weeks preoperatively. The primary outcomes (randomization percentage, recruitment rate, intervention adherence, follow-up completion, network development) will assess feasibility. Descriptive statistics will be used to characterize the study sample. DISCUSSION: The PREPARE pilot RCT will aim to provide feasibility and safety data that will allow for the successful completion of the definitive PREPARE trial that has the potential to provide practice changing data pertaining to the regular use of VLEDs as a means of pre-habilitation for patients with obesity undergoing major non-bariatric surgery. TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov (reference #NCT05918471) on June 23, 2023.

PREscribing preoperative weight loss prior to major non-bariatric abdominal surgery for patients with Elevated weight: Patient and Provider Survey Protocols (PREPARE surveys).

BACKGROUND: Preoperative very low energy diet (VLED) interventions are used routinely in patients undergoing bariatric surgery, a surgical subspecialty that deals almost exclusively with patients with obesity. Yet, their use and study has been limited in non-bariatric abdominal surgery. To investigate the use of VLEDs in non-bariatric surgery, we plan on conducting a randomized controlled trial (RCT). Prior to proceeding, however, we have designed two surveys as important pre-emptive studies aimed at elucidating patient and provider perspectives regarding these interventions. METHODS: The patient survey is a cross-sectional, single-center survey aimed at assessing the safety, adherence, barriers to adherence, and willingness to participate in preoperative optimization protocols with VLEDs prior to undergoing elective non-bariatric intra-abdominal surgery (S1 File). The population of interest is all adult patients with obesity undergoing elective non-bariatric intra-abdominal surgery at St. Joseph's Healthcare Hamilton who were prescribed a course of preoperative VLED. The primary outcomes will be safety and adherence. The target sample size is 35 survey responses. The provider survey is a cross-sectional national survey of practicing surgeons in Canada who perform major non-bariatric abdominal surgery aimed assessing the willingness and ability to prescribe preoperative weight loss interventions amongst practicing Canadian surgeons who perform major non-bariatric abdominal surgery (S2 File). The population of interest is independent practicing surgeons in Canada who perform major non-bariatric abdominal surgery. The primary outcome will be willingness to prescribe preoperative VLED to patients with obesity undergoing major non-bariatric abdominal surgery for both benign and malignant indications. The target sample size is 61 survey responses. Descriptive statistics will be used to characterize the sample populations. To determine variables associated with primary outcomes in the surveys, regression analyses will be performed. DISCUSSION: These survey data will ultimately inform the design of an RCT evaluating the efficacy of preoperative VLEDs for patients with obesity undergoing major abdominal surgery.

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.

Measurement and reporting of physical rehabilitation interventions in pediatric critical care: a scoping review.

PURPOSE: To describe and evaluate physical rehabilitation research in critically ill children, including physical rehabilitation intervention reporting. METHODS: We searched five electronic databases to 31 December 2018 for prospective physical rehabilitation studies conducted in pediatric intensive care units (PICU). Screening was conducted independently in duplicate. Study characteristics, outcomes, and interventions were extracted from included studies. Quality of study reporting was assessed using standardized tools. Completeness of physical rehabilitation intervention reporting was assessed using the Consensus on Exercise Reporting Template (CERT). RESULTS: We included 20 studies enrolling a total of 2644 patients. Median (Q1,Q3) sample size was 57 (44,104). Seven studies (35%) were randomized controlled trials. Eleven studies (55%) evaluated respiratory interventions, most commonly multicomponent chest physiotherapy (73%). Nine studies (45%) evaluated physical activity interventions, most commonly progressive mobility (56%). The majority of stated outcomes (92.5%) were limited to the PICU setting. Median [Q1,Q3] quality of study reporting was good (77.2% [66.7%,87.4%]), and completeness of physical rehabilitation intervention reporting was moderate (61.9% [45.9%,71.5%]). CONCLUSION: Physical rehabilitation studies in critically ill children were small, and focused on evaluating respiratory-based interventions and short-term PICU-based outcomes. Reporting of physical rehabilitation interventions was suboptimal. Use of CERT may improve design and reporting in future studies.Implications for rehabilitationWhile physical rehabilitation research in critically ill children is a growing field, there are currently few studies evaluating physical rehabilitation interventions in this population.Physical rehabilitation studies to date have been small, focused on evaluating respiratory-based interventions and short-term outcomes limited to the PICU setting.The reporting of physical rehabilitation interventions in this population is suboptimal, making it challenging for clinicians to reproduce interventions and appraise their efficacy or safety.

The emergence of the physician assistant role in a Canadian acute care surgery setting.

BACKGROUND: The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital. METHODS: To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017. RESULTS: The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period. CONCLUSION: Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.

CONTEXTE: Les adjoints au médecin (AM) jouent un rôle croissant dans les soins chirurgicaux au Canada. Suivant la même tendance, le modèle de chirurgie en soins actifs (CSA) poursuit son évolution, et on considère de plus en plus les AM comme des membres des équipes de CSA. Cependant, les retombées de leur travail et leur contribution ont été peu étudiées, et de façon imprécise. Notre étude décrit la contribution d'un AM travaillant à temps plein, en semaine, au sein d'une équipe de CSA dans un centre hospitalier universitaire canadien de soins tertiaires. MÉTHODES: Afin de quantifier la contribution de l'AM, nous avons créé une base de données de CSA en septembre 2016. Nous avons collecté les données ­ nombre de rencontres avec des patients, de consultations et d'admissions de l'équipe; participation de l'AM au bloc opératoire; nombre de rencontres de l'AM avec des patients; nombre de réunions multidisciplinaires ­ de manière prospective. Nos données décrivent une période de 365 jours consécutifs, qui s'étale du 30 décembre 2016 au 29 décembre 2017. RÉSULTATS: L'équipe de CSA a tenu 11 651 rencontres avec des patients dans l'année, pour une moyenne de 31,92 par jour. En moyenne, elle a réalisé 5,89 consultations et 2,08 interventions chirurgicales quotidiennement. L'AM a participé à 53,5 % des rencontres avec les patients, et ce malgré son horaire de jour et de semaine. L'AM a aussi dirigé 94,9 % des réunions multidisciplinaires, a vu 96,2 % des patients d'autres niveaux de soins, et a participé à 2,0 % des interventions au bloc opératoire. CONCLUSION: L'intégration d'un AM aux équipes de CSA est une valeur ajoutée pour les soins aux patients. Elle contribue à la gestion cohérente et efficace des événements au sein du service et des plans de soins, y compris la planification multidisciplinaire des congés, les consultations rapides à l'urgence et l'organisation efficace de l'équipe.

Operative timing is associated with increased morbidity and mortality in patients undergoing emergency general surgery: a multisite study of emergency general services in a single academic network.

Background: Despite the widespread implementation of the acute care surgery (ACS) model, limited access to operating room time represents a barrier to the optimal delivery of emergency general surgery (EGS) care. The objective of this study was to describe the effect of operative timing on outcomes in EGS in a network of teaching hospitals. Methods: We conducted a retrospective review of EGS operations performed at 3 teaching hospitals in a single academic network. Time of operation was categorized as daytime (8 am to 5 pm), after hours (5 pm to 11 pm) or overnight (11 pm to 8 am). Time to operation was calculated as the interval from admission to operative start time and categorized as less than 24 hours, 24-72 hours and greater than 72 hours. Results: After we excluded nonindex cases, trauma cases and cases occurring more than 5 days after admission, 1505 EGS cases were included. We found that 39.0% of operations were performed in the daytime, 46.3% after hours and 14.8% overnight. In terms of time to operation, 52.3% of operations were performed within 24 hours of admission, 33.4% in 24-72 hours and 14.3% in more than 72 hours. The overall complication rate was 20.6% (310 patients) and the overall mortality rate was 3.8% (57 patients). After multivariable analysis, time to operation more than 72 hours after admission was independently associated with increased odds of morbidity (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.09-2.47), while overnight operating was associated with increased odds of death (OR 3.15, 95% CI 1.29-7.70). Conclusion: Increasing time from admission to operation and overnight operating were associated with greater morbidity and mortality, respectively, for EGS patients. Strategies to provide timely access to the operating room should be considered to optimize care in an ACS model.

Contexte: Même si le modèle de chirurgie en soins actifs (CSA) est largement répandu, l'accès limité aux blocs opératoires représente un obstacle à la chirurgie générale chez les patients des services d'urgence (CGSU). L'objectif de cette étude était de décrire l'effet du moment de l'intervention sur l'issue des CGSU dans un réseau d'hôpitaux universitaires. Méthodes: Nous avons procédé à une revue des CGSU effectuées dans 3 hôpitaux d'enseignement d'un réseau universitaire. Le moment opératoire était catégorisé selon que les interventions étaient effectuées le jour (8 h 00 à 17 h 00), le soir (17 h 00 à 23 h 00) ou la nuit (23 h 00 à 8 h 00). Le délai opératoire représentait l'intervalle entre l'admission et le début de l'intervention et était réparti selon les catégories suivantes : moins de 24 heures, de 24 à 72 heures et plus de 72 heures. Résultats: Après exclusion des cas non index, des cas de traumatologie et des cas survenus plus de 5 jours après l'admission, 1505 CGSU ont été incluses. Nous avons constaté que 39,0 % des interventions avaient été effectuées le jour, 46,3 % le soir et 14,8 % la nuit. Pour ce qui est du délai opératoire, 52,3 % des interventions ont été effectuées dans les 24 heures suivant l'admission, 33,4 % dans les 24 à 72 heures et 14,3 % plus de 72 heures après l'admission. Le taux global de complications a été de 20,6 % (310 patients) et le taux de mortalité global a été de 3,8 % (57 patients). Après analyse multivariée, le délai opératoire de plus de 72 heures suivant l'admission a été associé de manière indépendante à un risque accru de morbidité (rapport ces cotes [RC] 1,64, intervalle de confiance [IC]) de 95 % 1,09 à 2,47), tandis que les interventions effectuées la nuit ont été associées à un risque de décès plus élevé (RC 3,15, IC de 95 % 1,29 à 7,70). Conclusion: L'augmentation du délai entre l'admission et l'intervention et les interventions de nuit ont été associées à une morbidité et une mortalité plus élevées, respectivement, chez les patients soumis à des CGSU. Des stratégies visant à offrir un accès rapide aux blocs opératoires sont à envisager pour optimiser le modèle de CSA.