A lay of the land: a description of academic acute care surgery models in Canada.

BACKGROUND: Patients who require emergency general surgery (EGS) are at a substantially higher risk for perioperative morbidity and mortality than patients undergoing elective general surgery. The acute care surgery (ACS) model has been shown to improve EGS patient outcomes and cost-effectiveness. A recent systematic review has shown extensive heterogeneity in the structure of ACS models worldwide. The objective of this study was to describe the current landscape of ACS models in academic centres across Canada. METHODS: We sent an online questionnaire to the 18 academic centres in Canada. The lead ACS physicians from each institution completed the questionnaire, describing the structure of their ACS models. RESULTS: In total, 16 institutions responded, all of which reported having ACS models, with a total of 29 ACS services described. All services had resident coverage. Of the 29, 18 (62%) had dedicated allied health care staff. The staff surgeon was free from elective duties while covering ACS in 17/29 (59%) services. More than half (15/29; 52%) of the services described protected ACS operating room time, but only 7/15 (47%) had a dedicated ACS room all 5 weekdays. Four of 29 services (14%) had no protected ACS operating room time. Only 1/16 (6%) institutions reported a mandate to conduct ACS research, while 12/16 (75%) found ACS research difficult, owing to lack of resources. CONCLUSION: We saw large variations in the structure of ACS models in academic centres in Canada. The components of ACS models that are most important to patient outcomes remain poorly defined. Future research will focus on defining the necessary cornerstones of ACS models.

It all doesn't always have to go: abdominal wall reconstruction involving selective synthetic mesh explantation with biologic mesh salvage.

The comparative performance of synthetic and biologic meshes in complex and contaminated abdominal wall repairs remains controversial. Though biologic meshes are generally favoured in contaminated fields, this practice is based on limited data. Standard dictum regarding infected mesh is to either explant it early or pursue aggressive conservation measures depending on mesh position and composition. Explantation is typically morbid, leaving the patient with recurrent hernias and few reconstructive options. We report a case in which a hernia repaired with synthetic mesh recurred and was reconstructed with underlay biologic mesh. Delayed wound hematoma occurred after initiating anticoagulation for late postoperative pulmonary embolism, which became chronically infected. After multiple failed attempts at medical and interventional salvage of the mesh infection, the patient underwent selective explantation of synthetic mesh with conservation of the underlying biological mesh. She recovered completely without recurrent abdominal wall failure at long-term follow-up. We suggest the "salvageable" characteristics of biologic meshes may allow conservation, rather than explantation, in select cases of infection.

Is the type of biomesh relevant in the prevention of recurrence following abdominal wall reconstruction? A randomized controlled trial.

BACKGROUND: Complex abdominal wall reconstruction technique remains controversial. The use of biologic mesh products is also debated in active infection, sepsis prophylaxis and high-risk patients. Differences in biologic mesh technology and cost remain significant. We aimed to compare the efficacy of 2 commonly used biologic meshes in regards to hernia recurrence at 1 year. METHODS: This study was a parallel, dual-arm, double-blind randomized controlled trial involving adult patients undergoing complex abdominal wall reconstruction with a biologic mesh at a quaternary care institution (2017-2020). Patients were randomly assigned to receive Permacol (cross-linked) compared with Strattice (not crosslinked). The main outcome measure was hernia recurrence at 1 or more years following the index repair. RESULTS: We included 94 patients randomized to undergo reconstruction with 1 of 2 commonly used biologic mesh products (mean age 59.4 yr, standard deviation [SD] 9.9; 51% female; body mass index 32.9, SD 6.8). We found no significant differences between the groups (patient comorbidities, hernia recurrence risk factors, hernia size or infection profiles). Hernia recurrence rates (15%) were similar between groups (median 783 days of follow up, interquartile range 119). We found there was significantly less of a need for a component separation technique in the Strattice group (69% v. 87%). All other secondary outcome measures were equivalent between study arms. Multivariate analysis identified hepatic transplantation (odds ratio [OR] 1.94, 95% confidence intervals [CI] 0.33-4.41), active abdominal wall infection (OR 2.01, 95% CI 0.50-7.01), and more than 1 previous hernia repair (OR 2.68, 95% CI 0.41-5.99) as risk factors for subsequent hernia recurrence; however, there was no difference in recurrence factors between patient study groups. CONCLUSION: Given similar clinical performance between the 2 most commonly used biologic mesh products, the most cost effective mesh should be used in cost-conscious health care systems.

Prioritizing resident and patient safety while maintaining educational value: emergency restructuring of a Canadian surgical residency program during COVID-19.

Summary: Surgical programs are facing major and fluctuating changes to the resident workforce because of decreased elective volumes and high exposure risk during the coronavirus disease 2019 pandemic. Rapid restructuring of a residency program to protect its workforce while maintaining educational value is imperative. We describe the experience of the Division of General Surgery at the University of Ottawa in Ontario, Canada. The residency program was restructured to feature alternating "on" and "off" weeks, maintaining a healthy resident cohort in case of exposure. Teams were restructured and subdivided to maximize physical distancing and minimize resident exposure to pathogens. Educational initiatives doubled, with virtual sessions targeting every resident year and incorporating intraoperative teaching. The divisional research day and oral exams proceeded uninterrupted, virtually. A small leadership team enabled fast and flexible restructuring of a system for patient care while prioritizing resident safety and maintaining a commitment to resident education in a pandemic.