Global Makeup of Cardiothoracic Surgeons as Represented by Our Major Societies and Associations.

BACKGROUND: Prior efforts to capture the cardiothoracic surgery community rely on survey data with potentially biased or low response rates. Our goal is to better understand our community by assessing the membership directories from The Society of Thoracic Surgeons (STS), American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), and Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS). METHODS: Membership data were obtained from membership directories. Data for STS and EACTS were supplemented by the associations from their internal databases. The inclusion criterion was active membership; trainees and wholly incomplete profiles were excluded. RESULTS: A total of 12 053 membership profiles were included (STS, 6365; EACTS, 3661; AATS, 1495; ASCVTS, 532). Membership is 7% female overall (EACTS, 9%; STS, 6%; AATS, 5%; ASCVTS, 3%), with a median age of 57 years (STS, 60 years; EACTS, 52 years). All societies had a broad scope of practice including members who practiced both adult cardiac and thoracic (20% overall), but most members practiced adult cardiac (31% overall; ASCVTS, 48%; AATS, 36%; EACTS, 30%; STS, 28%) and were in the late stage of their careers. CONCLUSIONS: We present the makeup of our 4 major societies. We are global with a diversity of careers but concerning factors that require immediate attention. The future of our specialty depends on our ability to evolve, to promote the specialty, to attract trainees, and to include and promote female surgeons. It is crucial that we wake up to these issues, change the narrative, and create action on both individual and leadership levels.

Lung hemorrhage in trauma: Technical tricks and tips.

At some point as the on-call trauma surgeon, you may need to operate on a bleeding lung. This concise review addresses preoperative and intraoperative considerations for traumatic lung injuries, including how to deal with specific findings at the time of surgery.

Synchronous colorectal liver metastases: a national survey of surgeon opinions on simultaneous resection and multidisciplinary cooperation.

BACKGROUND: The management of patients with synchronous colorectal liver metastases (sCRLM) has evolved significantly (improved chemotherapy, hepatic surgery advancements, colonic stenting, consultation synergies). We sought to better understand surgeon viewpoints on optimal referral patterns and the delivery of simultaneous resections. METHODS: A 40 question on-line survey was offered to members of the Canadian surgical community. Statistical analysis was descriptive. RESULTS: A total of 52 surgeons responded. Most colorectal surgeons (CRS) had access to and a good working relationship with regional hepatobiliary (HPB) surgeons (86%) and medical oncologists (100%). The majority (92%) believed there was a role for simultaneous resection of sCRLM, with 69% having first hand experience. Many CRS (62%) discussed all cases of known hepatic metastases with HPB prior to any resection. When a lesion was asymptomatic/minimally symptomatic, most CRS (92%) discussed them with medical oncology/HPB prior to resection (8%). Bilobar metastases (58%), patient comorbidities (35%), portal lymphadenopathy (35%), and patient age (15%) restricted CRS from obtaining HPB consultations. Many CRS (46%) did not believe that resecting hepatic metastases prior to the primary lesion might be beneficial. Most CRS (60%) reported they could not accurately predict hepatic resectability, with only 27% familiarity with evidence-based guidelines. Despite working in smaller hospitals with less access to HPB and less experience with simultaneous resections, non-CR general surgeons more commonly supported a 'liver-first' approach. CONCLUSIONS: There was general agreement between CRS and general surgeons on numerous topics, but additional education is required with regard to HPB surgical capabilities and to provide truly individualized patient-centered care.

Practice and attitudes regarding double gloving among staff surgeons and surgical trainees.

BACKGROUND: Despite supporting evidence, many staff surgeons and surgical trainees do not routinely double glove. We performed a study to assess rates of and attitudes toward double gloving and the use of eye protection in the operating room. METHODS: We conducted an electronic survey among all staff surgeons and surgical trainees at 2 tertiary care centres in Alberta between September and November 2015.We analyzed the data using log-binomial regression for binary outcomes to account for multiple independent variables and interactions. For 2-group comparisons, we used a 2-group test of proportions. RESULTS: The response rate was 34.3% (361/1051); 205/698 staff surgeons (29.4%) and 156/353 surgical trainees (44.2%) responded. Trainees were more likely than staff surgeons to ever double glove in the operating room (p = 0.01) and to do so routinely (p = 0.01). Staff surgeons were more likely than trainees to never double glove (p = 0.01). A total of 300/353 respondents (85.0%) reported using eye protection routinely in the operating room. Needle-stick injury was common (184 staff surgeons [92.5%], 115 trainees [74.7%]). Reduced tactile feedback, decreased manual dexterity and discomfort/poor fit were perceived barriers to double gloving. CONCLUSION: Rates of double gloving leave room for improvement. Surgical trainees were more likely than staff surgeons to double glove. Barriers remain to routine double gloving among staff surgeons and trainees. Increased education on the benefits of double gloving and early introduction of this practice may increase uptake.

CONTEXTE: Malgré les preuves à l'appui, plusieurs chirurgiens en poste et chirurgiens en formation n'utilisent pas d'emblée le double gantage. Nous avons procédé à une étude pour évaluer le taux d'utilisation du double gantage, les opinions à son endroit et l'utilisation de la protection oculaire au bloc opératoire. MÉTHODES: Nous avons envoyé un sondage électronique à tous les chirurgiens en poste et chirurgiens en formation de 2 centres de soins tertiaires de l'Alberta entre septembre et novembre 2015. Nous avons analysé les données à l'aide d'un modèle de régression logarithmique binomiale pour les résultats binaires afin de tenir compte des variables indépendantes et des interactions. Pour les comparaisons à 2 groupes, nous avons utilisé le test de comparaison de 2 proportions. RÉSULTATS: Le taux de réponse a été de 34,3 % (361/1051); 205 chirurgiens en poste sur 698 (29,4 %) et 156 chirurgiens en formation sur 353 (44,2 %) ont répondu. Au bloc opératoire, les stagiaires étaient plus susceptibles de doubler leurs gants que les chirurgiens en poste (p = 0,01) et de le faire d'emblée (p = 0,01); et les chirurgiens en poste étaient plus susceptibles de ne jamais doubler leurs gants que les stagiaires (p = 0,01). En tout 300 répondeurs sur 353 (85,0 %) ont dit utiliser d'emblée une protection oculaire au bloc opératoire. Les piqûres d'aiguille accidentelles ont été fréquentes (184 chez les chirurgiens en poste [92,5 %], 115 chez les stagiaires [74,7 %]). Une réduction de la sensibilité tactile et de la dextérité manuelle et l'inconfort ou le piètre ajustement ont été les obstacles perçus au double gantage. CONCLUSION: Les taux de double gantage laissent à désirer. Les chirurgiens en formation sont plus susceptibles d'adopter le double gantage que les chirurgiens en poste. Des obstacles continuent de nuire à l'utilisation du double gantage d'emblée, tant chez les chirurgiens en poste que chez les chirurgiens en formation. Une meilleure sensibilisation aux avantages du double gantage et l'introduction de cette pratique dès le début de la formation pourrait faciliter son adoption.

Assessing resectability of colorectal liver metastases: How do different subspecialties interpret the same data?

BACKGROUND: Multimodal treatment of colorectal liver metastases (CRLMs) relies on precise upfront assessment of resectability. Variability in the definition of resectable disease and the importance of early consultation by a liver surgeon have been reported. In this pilot study we investigated the initial resectability assessment and patterns of referral of patients with CRLMs. METHODS: Surgeons and medical oncologists involved in the management of colorectal cancer at 2 academic institutions and affiliated community hospitals were surveyed. Opinions were sought regarding resectability of CRLMs and the type of initial specialty referral (hepatobiliary surgery, medical oncology, palliative care or other) in 6 clinical cases derived from actual cases of successfully performed 1- or 2-stage resection/ablation of hepatic disease. Case scenarios were selected to illustrate critical aspects of assessment of resectability, best therapeutic approaches and specialty referral. Standard statistical analyses were performed. RESULTS: Of the 75 surgeons contacted, 64 responded (response rate 85%; 372 resectability assessments completed). Hepatic metastases were more often considered resectable by hepatobiliary surgeons than all other respondents (92% v. 57%, p < 0.001). Upfront systemic therapy was most commonly prioritized by surgical oncologists (p = 0.01). Hepatobiliary referral was still considered in 73% of "unresectable" assessments by colorectal surgeons, 59% of those by general surgeons, 57% of those by medical oncologists and 33% of those by surgical oncologists (p = 0.1). CONCLUSION: Assessment of resectability varied significantly between specialties, and resectability was often underestimated by nonhepatobiliary surgeons. Hepatobiliary referral was not considered in a substantial proportion of cases erroneously deemed unresectable. These disparities result largely from an imprecise understanding of modern surgical indications for resection of CRLMs.

CONTEXTE: Le traitement multimodal des métastases hépatiques du cancer colorectal (MHCR) repose sur une rigoureuse évaluation initiale de la résécabilité. On a fait état de l'imprécision de la définition de résécabilité et de l'importance de demander rapidement une consultation en chirurgie du foie. Au cours de cette étude, nous avons fait le point sur l'évaluation initiale de la résécabilité et sur les types de consultations demandées pour les patients présentant des MHCR. MÉTHODES: Nous avons interrogé les chirurgiens et oncologues médicaux responsables de la prise en charge du cancer colorectal dans 2 établissements universitaires et leurs hôpitaux communautaires affiliés. Nous leur avons demandé leur opinion sur la résécabilité des MHCR et le type de consultation demandée initialement (chirurgie hépatobiliaire, oncologie médicale, soins palliatifs ou autres) concernant 6 cas cliniques inspirés de cas réels de résection ou ablation réussie pour maladie hépatique de stade 1 ou 2. Ces scénarios de cas cliniques ont été choisis pour illustrer certains aspects cruciaux de l'évaluation de la résécabilité, des approches thérapeutiques optimales et des demandes de consultation. Des analyses statistiques standards ont été effectuées. RÉSULTATS: Parmi les 75 chirurgiens rejoints, 64 ont répondu (taux de réponse 85 %; 372 évaluations de résécabilité ont été effectuées). Les métastases hépatiques ont été plus souvent jugées résécables par les chirurgiens hépatobiliaires que par tous les autres répondants (92 % c. 57 %, p < 0,001). Un traitement systémique initial a le plus souvent été privilégié par les chirurgiens-oncologues (p = 0,01). Une consultation auprès de spécialistes hépatobiliaires était encore considérée comme nécessaire pour les cas jugés «â€¯non résécables ¼ dans une proportion de 73 % par les chirurgiens spécialistes du cancer colorectal, de 59 % par les chirurgiens généraux, de 57 % par les oncologues médicaux et de 33 % par les chirurgiens-oncologues (p = 0,1). CONCLUSION: L'évaluation de la résécabilité a significativement varié d'une spécialité à l'autre et la résécabilité a souvent été sous-estimée par les chirurgiens non spécialistes de voies hépatobiliaires. La consultation auprès des spécialistes hépatobiliaires n'a pas été envisagée pour une proportion substantielle de cas jugés à tort non résécables. Ces disparités se soldent en bonne partie d'une mécompréhension des indications actuelles de la chirurgie pour MHCR.

Examples of dramatic failures and their effectiveness in modern surgical disciplines: can we learn from our mistakes?

Innovation can be variably defined, but when applied to healthcare is often considered to be the introduction of something new, whether an idea, method or device, into an unfilled void or needy environment. Despite the introduction of many positive surgical subspecialty altering concepts/devices however, epic failures are not uncommon. These failures can be dramatic in regards to both their human and economic costs. They can also be very public or more quiet in nature. As surgical leaders in our communities and advocates for patient safety and outcomes, it remains crucial that we meet new introductions in technology and patient care with a measured level of curiosity, skepticism and science-based conclusions. The aim of an expert committee was to identify the most dominant failures in technological innovation and/or dogmatic clinical beliefs within each major surgical subspecialty. In summary, this effort was pursued to highlight the past failures and remind surgeons to remain vigilant and appropriately skeptical with regard to the introduction of new innovations and clinical beliefs within our craft.

One thousand consecutive in-hospital deaths following severe injury: Has the etiology of traumatic inpatient death changed in Canada?

SUMMARY: A wide range of factors have traditionally led to early in-hospital death following severe injury. The primary goal of this commentary was to evaluate the causes of early posttraumatic inpatient deaths over an extended period. Although early posttraumatic in-hospital death remains multifactorial, severe traumatic brain injuries are the dominant cause and have increased in proportion over time. Other traditional causes of death have also decreased owing to improved clinical care.

Management of haemothoraces in blunt thoracic trauma: study protocol for a randomised controlled trial.

INTRODUCTION: Haemothorax following blunt thoracic trauma is a common source of morbidity and mortality. The optimal management of moderate to large haemothoraces has yet to be defined. Observational data have suggested that expectant management may be an appropriate strategy in stable patients. This study aims to compare the outcomes of patients with haemothoraces following blunt thoracic trauma treated with either chest drainage or expectant management. METHODS AND ANALYSIS: This is a single-centre, dual-arm randomised controlled trial. Patients presenting with a moderate to large sized haemothorax following blunt thoracic trauma will be assessed for eligibility. Eligible patients will then undergo an informed consent process followed by randomisation to either (1) chest drainage (tube thoracostomy) or (2) expectant management. These groups will be compared for the rate of additional thoracic interventions, major thoracic complications, length of stay and mortality. ETHICS AND DISSEMINATION: This study has been approved by the institution's research ethics board and registered with ClinicalTrials.gov. All eligible participants will provide informed consent prior to randomisation. The results of this study may provide guidance in an area where there remains significant variation between clinicians. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT03050502.

Efficacy of a Dual-ring Wound Protector for Prevention of Surgical Site Infections After Pancreaticoduodenectomy in Patients With Intrabiliary Stents: A Randomized Clinical Trial.

OBJECTIVE: To evaluate the efficacy of a dual-ring wound protector for preventing incisional surgical site infection (SSI) among patients with preoperative biliary stents undergoing pancreaticoduodenectomy (PD). METHODS AND ANALYSIS: This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients with a biliary stent undergoing elective PD at 2 tertiary care institutions were included (February 2013 to May 2016). Patients were randomly assigned to receive a surgical dual-ring wound protector or no wound protector, and also the current standard of care. The main outcome measure was incisional SSI, as defined by the Centers for Disease Control and Prevention criteria, within 30 days of the index operation. RESULTS: A total of 107 patients were recruited (mean age 67.2 years; standard deviation 12.9; 65% male). No significant differences were identified between the intervention and control groups (age, sex, body mass index, preoperative comorbidities, American Society of Anesthesiologists class, prestent cholangitis). There was a significant reduction in the incidence of incisional SSI in the wound protector group (21.1% vs 44.0%; relative risk reduction 52%; P = 0.010). Patients with completed PD also displayed a decrease in incisional SSI with use of the wound protector compared with those palliated surgically (27.3% vs 48.7%; P = 0.04). Multivariate analysis did not identify any significant modifying factor relationships (estimated blood loss, duration of surgery, hospital site, etc.) (P > 0.05). CONCLUSION: Among adult patients with intrabiliary stents, the use of a dual-ring wound protector during PD significantly reduces the risk of incisional SSI.

National practice variation in pneumonectomy perioperative care among Canadian thoracic surgeons.

OBJECTIVES: Our objective was to assess perioperative pneumonectomy practices among Canadian thoracic surgeons as part of a quality-improvement initiative to determine practice variability and identify areas for study/improvement. METHODS: After several rounds of survey development and piloting, a 29-item survey was distributed using the Dillman method to all practicing members of the Canadian Association of Thoracic Surgeons. RESULTS: The response rate was 87% (62 of 71). Median number of pneumonectomies performed annually was 3.5 (interquartile range 2.75-5.00). Routine preoperative workup was variable, but the most consistently reported tests were diffusing capacity of the lungs for carbon monoxide (87%, n = 54) and spirometry (85%, n = 53). Reported routine use of epidurals (84%, n = 52) was more prevalent than paravertebral blocks (18%, n = 11). Many (69%, n = 43) reported intraoperative restriction <2 l. Postoperatively, 84% (n = 52) reported daily fluid restriction <2 l. Regarding intraoperative protective ventilation strategies, respondents appeared more focused on minimizing peak airway pressures (55%, n = 34) rather than tidal volumes (18%, n = 11). Twenty-four percent (n = 15) reported using intraoperative steroids in attempts to decrease postoperative complications. Thirty-two percent (n = 20) do not routinely insert chest tubes, whereas the most common practice (44%, n = 27) was to insert chest tubes attached to conventional drainage systems without suction. Eighty-two percent (n = 52) reported willingness to participate in multicentre studies regarding perioperative pneumonectomy practices. CONCLUSIONS: Our findings suggest significant variability in reported preoperative, intraoperative and postoperative care practices for pneumonectomy across Canada. This survey has a high response rate, representing the Canadian experience, and highlights several areas for study and quality-improvement initiatives. Many respondents report willingness to participate in multicentre initiatives.

Does increased prehospital time lead to a "trial of life" effect for patients with blunt trauma?

BACKGROUND: Variance in prehospital time among severely injured blunt trauma patients is dependent upon numerous factors. Effects on subsequent mortality and trauma team activation (TTA) rates are also unclear. The primary aim of this study was to evaluate the relationship between prehospital time and mortality at level I trauma referral centers amongst critically blunt injured patients. MATERIALS AND METHODS: This multiinstitutional study from three geographically distinct level I trauma centers analyzed all severely blunt injured patients (Injury Severity Score [ISS] ≥12). The relationship between prehospital time and survival was evaluated. Secondary outcomes included the association between prehospital time and TTA. Standard statistical methodology was used (P < 0.05 = significance). RESULTS: Between January 1, 2011, and January 1, 2016, 5375 severely blunt injured patients (mean ISS = 25; mean length of stay = 16.3 d) were analyzed (center 1 = 3376; center 2 = 2401; and center 3 = 1104). As prehospital time interval increased, overall mortality decreased (0-30 min = 24.1%; 31-60 min = 14.7%; 61-90 min = 10.3%; 91-120 min = 10.4%; 121-150 min = 10.2%; P < 0.05). This pattern was especially strong for patients with an arrival measurement of hypotension, despite corrections for ISS (P < 0.05). TTA and patient outcomes were extremely variable across intervals and centers (P < 0.05). CONCLUSIONS: A trial of life effect is present for severely blunt injured patients who arrive with vital signs. Despite arrival measurements of hypotension, patients with prolonged prehospital times have a substantially lower risk of subsequent mortality. This concept should contribute to decision-making with regard to TTA.

The adequacy of hepatopancreatobiliary training: How does operative exposure and perceived readiness in fellowship translate into subsequent practice?

SUMMARY: Over the last 3 decades, expansion in the scope and complexity of hepatopancreatobiliary (HPB) surgery has resulted in significant improvements in postoperative outcomes. As a result, the importance of dedicated fellowship training for HPB surgery is now well established, and the definition of formal program requirements has been actively pursued by a collaboration of the 3 distinct accrediting bodies within North America. While major advances have been made in defining minimum case volume requirements, qualitative assessment of the operative experience remains challenging. Our research collaborative (HPB Manpower and Education Study Group) has previously explored the perceived case volume adequacy of core HPB procedures within fellowship programs. We conducted a 1-year follow-up survey targeting the same cohort to investigate the association between operative case volumes and comfort performing HPB procedures within initial independent practice.

The efficacy of a novel saline/bipolar radiofrequency energy instrument for arresting ongoing solid and non-solid organ hemorrhage in a swine model.

INTRODUCTION: Ongoing hemorrhage is often life threatening and can be challenging to stop in critically injured patients. Traditional techniques for addressing this issue include high voltage cautery (Bovie), topical hemostatic application, and the delivery of ignited argon gas. The goal of this study was to evaluate the efficacy of a novel energy device for arresting ongoing bleeding from both solid and non-solid organs within a swine model. METHODS: A novel instrument utilizing bipolar radiofrequency (RF) energy which acts to ignite/boil dripping saline from a small hand piece was employed to arrest ongoing hemorrhage from an escalating series of injuries in large male swine. Liver, spleen, kidney, lung, heart, inferior vena cava and abdominal wall targets were evaluated and digitally recorded. Methodology was descriptive. RESULTS: Four large male swine received escalating injuries to their liver, spleen, kidney, lung, heart, inferior vena cava and abdominal wall. Injury patterns included a variety of surface decapsulation, superficial lacerations, deep lacerations, "through and through" missiles and complete transections. Application of the bipolar/RF instrument to sites of ongoing hemorrhage was successful in 97% of all scenarios. Depth of tissue penetration via microscopic evaluation ranged from 1.1mm to 3.0mm depending on the target organ composition. No air leaks were observed following application to the bleeding lung. Surgeon reported 'ease of use' score was high (4.8/5). CONCLUSION: This energy technology is successful in arresting ongoing hemorrhage from varying intensities of traumatic injuries to the liver, spleen, kidney, abdominal wall, lung and heart in the swine model. Additional testing is required before advocating its use on any thoracic organs.