Resuscitative endovascular balloon occlusion of the aorta in Canada: a context-specific position paper from the Canadian Collaborative for Urgent Care Surgery (CANUCS).

SummaryResuscitative endovascular balloon occlusion of the aorta (REBOA) is a well-described intervention for noncompressible torso hemorrhage. Several Canadian centres have included REBOA in their hemorrhagic shock protocols. However, REBOA has known complications and equipoise regarding its use persists. The Canadian Collaborative on Urgent Care Surgery (CANUCS) comprises surgeons who provide acute trauma care and leadership in Canada, with experience in REBOA implementation, use, education and research. Our goal is to provide evidence- and experience-based recommendations regarding institutional implementation of a REBOA program, including multidisciplinary educational programs, attention to device and care pathway logistics, and a robust quality assurance program. This will allow Canadian trauma centres to maximize patient benefits and minimize risks of this potentially life-saving technology.

Management of vascular trauma across Canada: A cohort study with implications for practice.

BACKGROUND: The aim of this study was to provide a description of vascular trauma and its management at trauma centers across Canada. METHODS: This retrospective cohort study evaluated patients from 8 Canadian level 1 trauma centers (2011-2015). Medical records were queried to identify adult patients who survived to hospital with major vascular injury. Major vascular injury was defined as injury to named arterial or venous vessels in the legs, arms torso, and neck. Data collected included patient demographics, injury mechanism, injury details, management and clinical outcomes. RESULTS: A total of 1330 patients were included. Patients were 76% male with a mean age of 43 (SD 18.8). Reported injuries were 63% blunt, 36% penetrating, and the remainder mixed. The most common specific mechanisms of injury were motor vehicle collision (36%), stabbing (26%), and falls (16%), with gunshot injuries accounting for <5%. Pre-hospital tourniquets were applied in 27 patients (2%). The mean Injury Severity Score (ISS) was 24 (SD 14.5). We identified injuries to named vessels of the neck (32%), thorax (23%), abdomen and pelvis (27%), upper extremity (14%) and lower extremity (10%). Specific vascular injuries included transection (50%), complete occlusion (11%), partial occlusion (39%), and pseudoaneurysm formation (11%). Injuries were managed non-operatively in 32%, with definitive open surgical management (24%), endovascular management (9%) and with damage control techniques in the operating room (3%). Amputation occurred in 10% of lower extremity and 5% of upper extremity injuries. Responsibility for vascular injury management was undertaken by a wide variety of specialists (n = 17). Overall, in-hospital mortality was 13%, and 2% of patients underwent amputation. CONCLUSION: This study describes the nature and management of vascular injuries across Canada. The variability in injury mechanisms, management strategies, specialty responsible for management, and outcomes have important implications for practice change and knowledge translation.

Impact of interhospital transfer on patient outcomes in emergency general surgery.

BACKGROUND: Emergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers. METHODS: We performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority. RESULTS: A total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3-2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2-3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6-1.9]; P = .79) on regression analysis. CONCLUSION: Complex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.

Prospective study of single-stage repair of contaminated hernias with the novel use of calcium sulphate antibiotic beads in conjunction with biologic porcine submucosa tissue graft.

SUMMARY: In single-stage hernia repair in the setting of contaminated fields there is a high rate of infection following mesh repair. New strategies to decrease infection in this challenging patient population are needed. Stimulan calcium sulfate antibiotic beads (CSAB) are a biodegradable material that deliver high concentrations of antibiotics locally to a site of insertion. Their use in the prevention of infection has not been described in hernia graft implantation. Here we describe our use of CSAB in a series of 11 patients with modified Ventral Hernia Working Group class III and Centers for Disease Control and Prevention class II-IV wounds undergoing single-stage incisional ventral hernia repair. We found that implantation of CSAB in single-stage hernia repair in the setting of contaminated fields was feasible with low systemic antibiotic levels. Further research should be undertaken to investigate the efficacy of this novel tool in hernia repair.

Patterns of complex emergency general surgery in Canada.

BACKGROUND: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. METHODS: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. RESULTS: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). CONCLUSION: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.

CONTEXTE: La plupart des études sur les services de chirurgie générale d'urgence (CGU) s'intéressent seulement aux atteintes de l'appendice et de la vésicule biliaire. Pourtant, les chirurgiens du domaine traitent beaucoup d'autres problèmes complexes. L'objectif de l'étude était de décrire le travail chirurgical associé à ces problèmes dans l'ensemble du Canada. MÉTHODES: Notre étude de cohorte rétrospective multicentrique inclut les patients adultes (≥ 18 ans) qui ont subi en 2014 une opération non planifiée pour une atteinte qui ne touchait ni l'appendice ni la vésicule biliaire dans 1 des 7 centres sélectionnés, répartis un peu partout au pays. Nous avons recueilli les données suivantes : renseignements de base des patients, diagnostic, détails de l'intervention, nature des complications et durée d'hospitalisation. Puis nous avons dégagé les facteurs prédictifs de morbidité et de mortalité en appliquant un modèle de régression logistique. RÉSULTATS: L'échantillon totalisait 2595 patients, pour un âge médian de 60 ans (écart interquartile 46­73 ans). Les diagnostics principaux les plus courants étaient l'occlusion de l'intestin grêle (16 %), la hernie (15 %), la tumeur maligne (11 %) et les lésions périanales (9 %). Les interventions les plus fréquentes étaient la résection de l'intestin (30 %), la réparation d'une hernie (15 %), le débridement (11 %) et le débridement de tissus mous ou cutanés infectés (10 %). L'opération a eu lieu le soir ou la nuit (entre 17 h et 8 h) dans 47 % des cas. Le taux global de mortalité à l'hôpital était de 8 %. Des complications sont survenues chez 33 % des patients, dont les facteurs prédictifs indépendants étaient l'âge avancé (p = 0,001), un score ASA (de l'American Society of Anesthesiologists) élevé (p = 0,02) et le transfert à partir d'un autre centre (p = 0,001). CONCLUSION: Cette étude dresse le profil épidémiologique des interventions effectuées par les services de CGU du Canada en présence d'atteintes autres que celles de l'appendice et de la vésicule biliaire. Les chirurgiens du pays font beaucoup d'interventions générales urgentes, pour traiter des affections associées à un risque élevé de morbidité et de mortalité. Les résultats de l'étude guideront les prochaines recherches et serviront de points de référence en matière d'amélioration de la qualité.

Correction to: Ethical considerations in conducting surgical research in severe complicated intra-abdominal sepsis.

[This corrects the article DOI: 10.1186/s13017-019-0259-9.].

Ethical considerations in conducting surgical research in severe complicated intra-abdominal sepsis.

Background: Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has been hypothesized to mitigate MOF and death, although clinical equipoise for this operative approach exists. The Closed or Open after Laparotomy (COOL) study (https://clinicaltrials.gov/ct2/show/NCT03163095) will prospectively randomize eligible patients intra-operatively to formal abdominal closure or OA with NPTT. We review the ethical basis for conducting research in SCIAS. Main body: Research in critically ill incapacitated patients is important to advance care. Conducting research among SCIAS is complicated due to the severity of illness including delirium, need for emergent interventions, diagnostic criteria confirmed only at laparotomy, and obtundation from anaesthesia. In other circumstances involving critically ill patients, clinical experts have worked closely with ethicists to apply principles that balance the rights of patients whilst simultaneously permitting inclusion in research. In Canada, the Tri-Council Policy Statement-2 (TCPS-2) describes six criteria that permit study enrollment and randomization in such situations: (a) serious threat to the prospective participant requires immediate intervention; (b) either no standard efficacious care exists or the research offers realistic possibility of direct benefit; (c) risks are not greater than that involved in standard care or are clearly justified by prospect for direct benefits; (d) prospective participant is unconscious or lacks capacity to understand the complexities of the research; (e) third-party authorization cannot be secured in sufficient time; and (f) no relevant prior directives are known to exist that preclude participation. TCPS-2 criteria are in principle not dissimilar to other (inter)national criteria. The COOL study will use waiver of consent to initiate enrollment and randomization, followed by surrogate or proxy consent, and finally delayed informed consent in subjects that survive and regain capacity. Conclusions: A delayed consent mechanism is a practical and ethical solution to challenges in research in SCIAS. The ultimate goal of consent is to balance respect for patient participants and to permit participation in new trials with a reasonable opportunity for improved outcome and minimal risk of harm.

Structured operative reporting: a randomized trial using dictation templates to improve operative reporting.

BACKGROUND: Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template. METHODS: Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation. RESULTS: There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group (P = .02). CONCLUSIONS: The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.

Using the intensive care unit to teach end-of-life skills to rotating junior residents.

BACKGROUND: This study tested the effectiveness and perceived value of a palliative/end-of-life (P/EOL) curriculum for junior residents implemented during an intensive care unit (ICU) rotation. METHODS: Residents rotating through the ICU over a 6-month period completed pre- and post-curriculum surveys evaluating their self-assessed efficacy in providing P/EOL care and attitudes towards P/EOL care. Scores were analyzed using a paired Student t test. RESULTS: Seventeen of 19 (90%) residents completed both the pre- and post-curriculum evaluations. The P/EOL curriculum increased self-assessed efficacy ratings in the domains of pain management (P = .04), psychosocial knowledge (P = .001), communicator knowledge (P = .001), professional knowledge (P = .002), and manager knowledge (P < .001). The rotation was rated as being valuable in preparing residents to care for patients near the end-of-life (P < .05), with surgery residents indicating it to be the most valuable rotation in their training program for learning about P/EOL care. CONCLUSIONS: An ICU P/EOL curriculum improves self-assessed efficacy scores across multiple domains in P/EOL care and is seen as a valuable educational experience.

Why are women deterred from general surgery training?

BACKGROUND: This study explored the factors contributing to the low application rates to general surgery (GS) residency by female students and compared perceptions of GS between students and female surgeons. METHODS: We distributed surveys to final-year students at 4 medical schools and nationwide to every female general surgeon in Canada. RESULTS: Of students who were deterred from GS, women were less likely than men to meet a same-sex GS role model and more likely to experience gender-based discrimination during their GS rotation (P < .05). Female students had the perception that GS was incompatible with a rewarding family life, happy marriage, or having children, whereas female surgeons were far more positive about their career choice. CONCLUSIONS: Both real and perceived barriers may deter women from a career in GS. Real barriers include sex-based discrimination and a lack of female role models in GS. There are also clear differences in perception between students and surgeons regarding family and lifestyle in GS that must be addressed.

A study of career choice patterns among Canadian medical students.

BACKGROUND: The number of students pursuing general surgery (GS) has declined in Canada. The reasons for this, and program directors' (PDs) perception of it, are unclear. METHODS: A survey was distributed to medical students at Queen's University and the University of Manitoba, and to all Canadian GS program directors to explore causes for the trend and identify potential solutions. RESULTS: Students pursuing GS were more likely to feel that GS fit their lifestyle needs (P < 0.05) and to have met positive role models (P < 0.05). Hardship of the training and practice, length of training, need for prestige, income and enjoyment of procedures did not correlate with specialty choice. Half of GS PDs did not perceive a decline in the number of applicants. CONCLUSIONS: Attention to student-raised concerns regarding GS programs and increased awareness of the applicants' trends among PDs can be used to address the current decline in applications to GS.

The in-house education of clinical clerks in surgery and the role of housestaff.

BACKGROUND: While on surgical rotations, clinical clerks spend more time on the ward and in the emergency department than in any other location. Consequently, their in-house experience is of great importance to their education-yet the teaching processes in these settings have never been fully explored. Unlike the structured pre-clerkship years, the exact breakdown of a clerk's hospital-based education is difficult to elucidate. To effectively evaluate a clerkship curriculum, it is essential to know what clerks are being taught outside of seminars, how that teaching occurs, and by whom. This study proposes a methodology by which a surgical clerkship curriculum can be evaluated. METHODS: For the purpose of the study, surgery clerks carried written and audio logs of their informal teaching encounters during one on-call period (30 hours). These included who taught them, where, by what methods, for how long, and what prompted the teaching. A survey of similar variables was administered to all clerks who rotated through general surgery over 4 months and to all general surgery residents. RESULTS: Four clerks returned completed logs (100% response rate), and 17 clerks (85% response) and 15 residents (100% response) were surveyed. Audiotaped and written logs were similar, demonstrating good recall. Students recorded an average of 11 teaching encounters (range 3 to 20) per 30 hour period, lasting a total of 73 minutes (range 17 to 178) and each 6.7 +/- 14 minutes long. Both logs and surveys identified most teaching as unsolicited, done mostly by junior and chief residents, focused chiefly on diagnosis and using a Socratic style. Most teaching occurred in the operating room, yet its occurrence was unpredictable; in surveys the emergency room and clinic settings were perceived as more important. Staff surgeons contributed 27% of the logged encounters yet were perceived in surveys as the least contributors. Residents' and clerks' perceptions of teaching were similar except for residents overvaluing the amount of senior teaching (P = 0.04). The resident level correlated significantly with the comfort of teaching (r = 0.618, P = 0.04). Senior residents encouraged more problem-solving, whereas juniors favored minilectures. Only one resident had received formal teaching instruction. CONCLUSIONS: Informal teaching of surgery clerks is variable and occurs through multiple short encounters in many settings and by various trainees. Efforts to improve the teaching process should focus on providing formal teaching instruction early in residency, specifically geared toward short encounters in flexible settings. Both the operating room as a learning environment and staff surgeons as informal teachers must be intentionally integrated into the teaching process.