Acute general surgery in Canada: a survey of current handover practices.

BACKGROUND: Today's acute care surgery (ACS) service model requires multiple handovers to incoming attending surgeons and residents. Our objectives were to investigate current handover practices in Canadian hospitals that have an ACS service and assess the quality of handover practices in place. METHODS: We administered an electronic survey among ACS residents in 6 Canadian general surgery programs. RESULTS: Resident handover of patient care occurs frequently and often not under ideal circumstances. Most residents spend less than 5 minutes preparing handovers. Clinical uncertainty owing to inadequate handover is most likely to occur during overnight and weekend coverage. Almost one-third of surveyed residents rate the overall quality of the handovers they received as poor. CONCLUSION: Handover skills must be taught in a systematic fashion. Improved resident communication will likely decrease loss of patient information and therefore improve ACS patient safety.

CONTEXTE: De nos jours, le modèle de service appliqué aux soins intensifs en chirurgie suppose de fréquents transferts de soins entre chirurgiens traitants et résidents. Nous avions pour objectifs d'analyser les pratiques actuelles en matière de transfert des soins dans les hôpitaux canadiens qui disposent de services de soins intensifs chirurgicaux et d'en évaluer la qualité. MÉTHODES: Nous avons administré un questionnaire électronique à des résidents en chirurgie (soins intensifs) inscrits à 6 programmes canadiens de chirurgie générale. RÉSULTANTS: Il y a souvent des transferts de soins entre résidents et dans bien des cas, ces transferts ne se déroulent pas dans des conditions idéales. La plupart des résidents consacrent moins de 5 minutes à préparer les transferts de soins. L'incertitude clinique associée à des transferts de soins inadéquats risque davantage de s'observer la nuit et la fin de semaine. Près du tiers des résidents interrogés ont déclaré que la qualité globale des transferts qu'ils recevaient était médiocre. CONCLUSIONS: Il faut adopter une approche systématique à l'enseignement des compétences nécessaires pour des transferts de soins cohérents. En améliorant la communication chez les résidents, on réduira probablement la perte de renseignements importants au sujet des patients et on améliorera par conséquent la sécurité des patients qui reçoivent des soins d'urgence en chirurgie.

Cost utility of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND: Early laparoscopic cholecystectomy for acute cholecystitis is safe and effective. However, the potential cost savings of this management strategy have not been well studied in a North American context. This study aimed to estimate the cost effectiveness of early laparoscopic cholecystectomy versus delayed laparoscopic cholecystectomy in Canada. METHODS: A decision analytic model estimating and comparing costs from a Canadian providing institution after either early or delayed laparoscopic cholecystectomy was used. The health care resources consumed were calculated using local hospital data, and outcomes were measured in quality-adjusted life years (QALYs) gained during 1 year. Uncertainty was investigated with one-way sensitivity analyses, varying the probabilities of the events and utilities. RESULTS: Early laparoscopic cholecystectomy was estimated to cost approximately $2,000 (Canadian dollars) less than delayed laparoscopic cholecystectomy per patient, with an incremental gain of approximately 0.03 QALYs. Sensitivity analysis showed that only extreme values of bile duct injury or bile leak altered the direction of incremental gain. CONCLUSIONS: Adoption of a policy in favor of early laparoscopic cholecystectomy will result in better patient quality of life and substantial savings to the Canadian health care system.

Hepatic artery transection reconstructed with splenic artery transposition graft.

INTRODUCTION: Hepatic artery transection presents a technical challenge in vascular reconstruction. Formal arterial repair is indicated in patients with underlying liver disease and those undergoing bile duct reconstructions because of a higher risk of complication following hepatic artery injury. This report highlights a novel approach to hepatic artery transection with splenic artery transposition. METHODS: A case of hepatic artery transection repaired with splenic artery transposition is presented with an accompanying literature review. RESULTS: During elective pancreaticoduodenectomy, the common hepatic artery was injured at its origin. The splenic artery was divided and transposed to the hepatic artery, thus restoring arterial flow to the liver and bile duct. CONCLUSION: Various strategies to manage a hepatic artery injury have been described, ranging from ligation to complex vascular reconstruction. In hemodynamically stable patients, arterial transposition using the splenic artery is a feasible method to ensure adequate arterial supply to the liver and biliary tract.

Detection and management of hypothyroidism following thyroid lobectomy: evaluation of a clinical algorithm.

BACKGROUND: The objectives of this study were to determine: (1) the incidence permanent hypothyroidism after thyroid lobectomy (TL), (2) whether asymptomatic patients with mildly elevated thyrotropin (TSH) levels can be managed without thyroid hormone replacement, and (3) if the degree of lymphocytic infiltration (LI) and germinal center (GC) formation in the resected thyroid lobe correlates with the development of post-TL hypothyroidism. METHODS: Subjects undergoing TL between January 2006 and January 2008 at 2 centers were enrolled in the study and thyroid function was followed prospectively based on a previously published algorithm. The histology of each resected thyroid lobe was examined, and the degree of LI and GC was quantified. RESULTS: The study cohort consisted of 117 patients. Early postoperative TSH levels were significantly increased over preoperative levels (P < .001). TSH measured at 6 months to 1 year postoperatively, while still significantly increased over preoperative levels (P < .001), was also significantly reduced (P = .006) compared with early postoperative levels. Of the patients who presented with early postoperative hypothyroidism, 69.2% recovered to normal levels without intervention. The overall incidence of early postoperative hypothyroidism was 21.6%, and permanent hypothyroidism was 7.8%. A high degree of LI and GC correlated with a significantly higher mean TSH level (P = .003). CONCLUSIONS: The incidence of hypothyroidism following TL is low, and a significant proportion of individuals who become biochemically hypothyroid will demonstrate only a transient elevation in their TSH levels. As well, individuals with LI, or GC formation, within their resected thyroid lobe may be at increased risk for post-TL hypothyroidism.

Planned ilioinguinal nerve excision for prevention of chronic pain after inguinal hernia repair: a meta-analysis.

BACKGROUND: Inguinal hernia repair is a common operative procedure, but the development of chronic postoperative pain is a dreaded potential complication. The role of neurectomy in decreasing the incidence of chronic pain after inguinal hernia repair is currently unknown. Our objective was to determine whether a planned ilioinguinal nerve excision results in a decrease in the development of chronic pain experienced after inguinal hernia repair. METHODS: A systematic literature review was carried out to identify studies investigating the influence of ilioinguinal nerve excision on the development of chronic pain after inguinal hernia repair. A quantitative analysis of the pooled data was carried out. RESULTS: Of 6,023 abstracts reviewed, 4 high-quality, randomized-controlled trials were identified. The pooled mean difference in degree of pain at 6 months postoperatively on a 10-point scale was -0.29 (95% confidence interval: -0.48 to -0.11), favoring neurectomy to decrease the chance of developing chronic pain. Not surprisingly, those individuals undergoing neurectomy were also more likely to develop altered sensation at the same time point (odds ratio: 3.70, 95% confidence interval: 2.61-5.25). CONCLUSION: A planned resection of the ilioinguinal nerve at the time of inguinal hernia repair is associated with a decrease in the incidence of chronic postoperative pain. Thus, carrying out this simple maneuver at the time of operation might decrease a major source of postoperative patient morbidity.

Abdominal wall desmoid tumors associated with pregnancy: current concepts.

The desmoid tumors (DTs) are unusual soft-tissue tumors that have a propensity for aggressive local growth and may develop during, or soon after pregnancy. Pregnancy-associated DTs are uncommon and optimal management of this tumor has yet to be defined. Currently, controversy centers on the timing of surgical resection and is influenced by the potential for tumor growth and the effects of a gravid uterus. A review of current literature in which DTs were managed either during pregnancy or in the postpartum period, was carried out. Surgical resection of these tumors has been performed successfully both during and soon after delivery, and the role of postpartum radiotherapy, chemotherapy and other medical intervention remains controversial. Management of DTs diagnosed during pregnancy is complex and treatment must be individualized.