Improving the management and outcomes of complex non-pedunculated colorectal polyps at a regional hospital in British Columbia.

BACKGROUND: Colorectal cancer arises from precancerous lesions, primarily adenomatous and serrated polyps. Some polyps pose significant technical endoscopic challenges due to their size, location, and/or morphology. A standardized protocol for documentation and management of these polyps can optimize clinical outcomes. METHODS: A Quality Improvement project compared patients with a complex polyp (non-pedunculated, > 2 cm), for 12 months prior and 12 months after protocol introduction. Documentation and polyp management details were compared pre- and post-implementation using the Chi-square test. RESULTS: 69 patients were diagnosed with complex polyps prior to the protocol introduction and 72 after. 79% (112/141) of patients underwent endoscopic mucosal resections (EMR) locally, and 14.9% (21/141) underwent surgery locally. After protocol introduction, there was significant improvement in documentation of suspicious appearing polyps (21.7% to 47.2%, P = 0.001), luminal circumference (14.5% to 34.7%, P = 0.005), and management plans (87.0% to 97.2%, P = 0.023); other elements of documentation were similar. The number of patients reviewed at multidisciplinary conference (MDC) increased from 1 to 61% (P < 0.005). Patients rebooked in a 1 h endoscopy time slot increased from 19 to 58% (P < 0.005), as did specific consent for EMR from 22 to 57% (P < 0.005). Among patients with polyps 3 cm or greater (23 pre, 36 post), MDC review increased from 4 to 67% (P < 0.005), primary polypectomy decreased from 72 to 23% (P = 0.001), patients rebooked in a double endoscopy slot increased from 33 to 75% (P = 0.005), and specific consent increased from 39 to 75% (P = 0.014). There were less polyp recurrences (12/42 pre and 1/50 post) among the post-protocol cohort (P < 0.001). CONCLUSIONS: The introduction of a formalized protocol for complex polyp adjudication and management has led to improved documentation, multidisciplinary discussion, and optimal complex polyp management with dedicated time for EMR, particularly for polyps over 3 cm. There is room for improvement, and this can be approached in a collaborative manner.

The impact of targeted fee increases on the pay disparity between female and male general surgeons in British Columbia.

BACKGROUND: High-level payment data provided by Doctors of BC showed a 19.7% pay disparity in annual payments between female and male general surgeons in fiscal year 2019/20, and this was previously as high as 30% in 2012/13. This study aimed to examine the impact of targeted fee increases on pay disparity by sex over time. METHODS: The top 35 fees billed by female general surgeons, representing 76.3% of total payments, were retrospectively analyzed. The pay disparity by sex was calculated for each individual fee from 2000/01 to 2019/20. RESULTS: There were notable billing differences between female and male general surgeons. Female surgeons billed breast oncology procedures, malignancy consultations and visits, and peritoneal malignancy surgical procedures in greater proportions than did their male counterparts. Male surgeons billed hemorrhoid banding and rigid proctosigmoidoscopy in greater proportions than their female counterparts. With targeted fee increases, pay disparity by sex worsened for 17 of the top 35 fees but improved for the other 18 from 2010/11 to 2019/20, to varying degrees, resulting in an overall reduction in pay disparity by sex from 23% to 15%. If across-the-board fee increases had been implemented instead of targeted fee increases, the disparity in 2019/20 would have been 19% instead of 15%. CONCLUSION: Targeted fee increases reduced pay disparity between male and female general surgeons compared with theoretical across-the-board fee increases in British Columbia from 2010/11 to 2019/20, but not uniformly; some fee increases resulted in increased disparity. Other physician groups should conduct a similar analysis and allocate future fee changes with the aim of improving rather than worsening disparity.

RAG time: rapid access general surgery - a shared-care protocol to convert after-hours inpatient to daytime outpatient surgery.

A rapid access general surgery (RAG) pilot protocol was implemented at the Vernon Jubilee Hospital in January 2021 in which surgeons seeing patients in the emergency department (ED) could access operating time set aside once per week. Appropriate patients discharged from the ED were scheduled into this time, usually with a different surgeon than the initial triaging surgeon. In this article, we discuss the outcomecs of the pilot project. This innovative reorganization of existing resources converted many patients from after-hours to scheduled outpatient daytime surgery with decreased hospital bed utilization.

Patient, operative and pain management factors influencing inpatient compared with surgical day care mastectomy procedures at a community hospital.

BACKGROUND: The COVID-19 pandemic highlighted the importance of maximizing same-day discharge after surgery to mitigate potential patient harms associated with inpatient admission and conserve valuable hospital resources. Adoption of same-day discharge after breast surgery, particularly mastectomy, has been slow despite recent research suggesting the physical and psychological benefits of same-day discharge after surgery. We sought to identify factors associated with inpatient compared with surgical day care mastectomy procedures at a community hospital in Vernon, British Columbia. METHODS: We conducted a retrospective chart review of all patients who underwent a total mastectomy without reconstruction at Vernon Jubilee Hospital, a 196-bed community hospital, between April 2016 and March 2019. Patient characteristics, operative variables and pain management were compared between inpatient and surgical day care mastectomy procedures. We also compared 7-day readmission, reoperation and complications. RESULTS: A total of 187 mastectomy patients were analyzed with 72 (38.5%) surgical day care procedures. Factors associated with inpatient procedures included longer operative time (66.1 min v. 53.5 min, p = 0.001), bilateral mastectomy (91% v. 9%, p = 0.01) and suspected or confirmed obstructive sleep apnea (32% v. 17%, p = 0.04). Preoperative acetaminophen (83% v. 17%, p < 0.001), multilevel intercostal block (83% v. 17%, p < 0.001) and a prescription for acetaminophen plus tramadol (58% v. 42%, p < 0.001) were associated with day care surgeries. There were no significant differences between the inpatient and surgical day care groups with respect to 7-day readmission, reoperation or postoperative complications. CONCLUSION: We found no significant differences in surgical outcomes between inpatients and those with same-day discharge after mastectomy procedures. These findings add to the growing body of evidence that surgical day care mastectomy procedures are safe in the community setting.

UBC Reticulum: a province-wide network promoting surgical excellence and continuous improvement of general surgery in British Columbia.

The University of British Columbia's (UBC) Division of General Surgery is a diverse group, including both academic and community surgeons. Since its launch in 2019, the UBC Reticulum website has been a transformative tool in engaging general surgeons, fellows, residents, students and researchers through its many features and user-created content, such as its messaging board, Netter, and Connect feature, which connects members based on their specialty, location, procedures and interests. Reticulum also serves as a valuable repository of educational resources and is instrumental in the division's goal of improving continuing medical education; the Reticulum mentorship grant program provides financial support for practising surgeons pursuing peer-mentorship projects. UBC Reticulum serves as a model for how to coordinate surgical education, research and quality improvement within diverse provincial divisions.

Introducing oncoplastic breast surgery in a community hospital.

Oncoplastic breast surgery (OPBS) has been shown to increase breast-conserving surgery with improved oncologic and cosmetic outcomes, but access to OPBS in Canada varies greatly. This article summarizes the impact of introducing OPBS in a community hospital. All breast oncology surgery cases performed before and after the introduction of OPBS by a single surgeon were reviewed. After implementing OPBS in our centre, breast conservation increased from 30% to 50%, and the positive margin rate decreased from 25% to 10%. The completion mastectomy rate was lower in patients who received OPBS, and this group had a slightly higher readmission rate for postoperative hematoma. This review suggests OPBS can be performed safely in the community setting with appropriate training and improve outcomes in breast surgery for patients in smaller centres.

Are we producing general surgeons who are ready for community or rural practice?

Summary: General surgery remains a broad and unclearly defined specialty in small and medium-sized communities, where general surgeons perform more subspecialty and non-core procedures than their urban counterparts. It is unclear what specific procedures are being performed or whether today's residents are being trained to meet community needs. We surveyed the members of the British Columbia (BC) Surgical Society and found that only 3% of BC's surgeons believe today's graduates are "definitely prepared" for a broad-based community practice. We also identified several non-core procedures performed more frequently by general surgeons in small and medium-sized communities. General surgery residency is narrowing its focus despite the fact that community general surgeons are maintaining a broad-based practice. To meet the needs of smaller communities, residency programs need to address the discrepancies that exist between the emphasis within the current training structure and the practice of our community surgeons.

Does ultrasonography accurately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital.

BACKGROUND: Acute cholecystitis is one of the most common diseases requiring emergency surgery. Ultrasonography is an accurate test for cholelithiasis but has a high false-negative rate for acute cholecystitis. The Murphy sign and laboratory tests performed independently are also not particularly accurate. This study was designed to review the accuracy of ultrasonography for diagnosing acute cholecystitis in a regional hospital. METHODS: We studied all emergency cholecystectomies performed over a 1-year period. All imaging studies were reviewed by a single radiologist, and all pathology was reviewed by a single pathologist. The reviewers were blinded to each other's results. RESULTS: A total of 107 patients required an emergency cholecystectomy in the study period; 83 of them underwent ultrasonography. Interradiologist agreement was 92% for ultrasonography. For cholelithiasis, ultrasonography had 100% sensitivity, 18% specificity, 81% positive predictive value (PPV) and 100% negative predictive value (NPV). For acute cholecystitis, it had 54% sensitivity, 81% specificity, 85% PPV and 47% NPV. All patients had chronic cholecystitis and 67% had acute cholecystitis on histology. When combined with positive Murphy sign and elevated neutrophil count, an ultrasound showing cholelithiasis or acute cholecystitis yielded a sensitivity of 74%, specificity of 62%, PPV of 80% and NPV of 53% for the diagnosis of acute cholecystitis. CONCLUSION: Ultrasonography alone has a high rate of false-negative studies for acute cholecystitis. However, a higher rate of accurate diagnosis can be achieved using a triad of positive Murphy sign, elevated neutrophil count and an ultrasound showing cholelithiasis or cholecystitis.

CONTEXTE: La cholécystite aiguë est l'une des maladies les plus répandues exigeant une chirurgie d'urgence. L'échographie est un test précis pour le dépistage de la cholélithiase, mais elle s'accompagne d'un taux élevé de diagnostics faux-négatifs de cholécystite aiguë. Le signe de Murphy et les analyses de laboratoire effectuées indépendamment ne sont pas non plus particulièrement précis. Cette étude a été conçue pour vérifier la précision de l'échographie dans le diagnostic de la cholécystite aiguë dans un hôpital régional. MÉTHODES: Nous avons passé en revue toutes les cholécystectomies d'urgence effectuées sur une période d'un an. Toutes les épreuves d'imagerie ont été examinées par un seul radiologue et toutes les analyses d'anatomopathologie, par un seul anatomopathologiste. Les examinateurs n'étaient pas au courant de leurs conclusions respectives. RÉSULTATS: En tout, 107 patients ont eu besoin d'une cholécystectomie d'urgence au cours de la période de l'étude; 83 ont subi une échographie. La concordance d'opinion entre les radiologues a été de 92 % en ce qui concerne l'échographie. Pour la cholélithiase, l'échographie a présenté une sensibilité de 100 %, une spécificité de 18 %, une valeur prédictive positive (VPP) de 81 % et une valeur prédictive négative (VPN) de 100 %. En ce qui concerne la cholécystite aiguë, l'échographie a présenté une sensibilité de 54 %, une spécificité de 81 %, une VPP de 85 % et une VPN de 47 %. Tous les patients souffraient de cholécystite chronique et 67 % présentaient une cholécystite aiguë à l'examen histologique. Alliée à un signe de Murphy positif et à une élévation de la numération des neutrophiles, une échographie révélant une cholélithiase ou cholécystite aiguë offrait une sensibilité de 74 %, une spécificité de 62 %, une VPP de 80 % et une VPN de 53 % pour ce qui est du diagnostic de la cholécystite aiguë. CONCLUSION: L'échographie seule a donné lieu à un taux élevé de diagnostics fauxnégatifs de la cholécystite aiguë. Toutefois, la précision diagnostique augmente lorsque l'on observe simultanément un signe de Murphy positif, une augmentation de la numération des neutrophiles et des signes de cholélithiase cholécystite aiguë à l'échographie.

Quality of life and surgical outcomes following laparoscopic surgery for refractory gastroesophageal reflux disease in a regional hospital.

BACKGROUND: Gastroesophageal reflux disease (GERD) is a prevalent condition leading to poor quality of life (QOL) in patients with refractory symptoms. Laparoscopic antireflux (LAR) surgery has been shown to improve QOL, and I sought to examine the surgical and QOL outcomes associated with LAR surgery over a 3-year period at a regional hospital. METHODS: Patients were given GERD-health related quality of life (GERD-HRQL) and SF-36 questionnaires preoperatively, at 6 months and at 12 or more months after surgery. I collected data on demographic and clinical characteristics and surgical outcomes. RESULTS: Of the 342 patients referred for GERD or dysphagia, 26 received LAR surgery during the study period. All 26 patients had symptoms refractory to medications; 19 had atypical symptoms and 8 had some form of chronic pain syndrome (CPS). The mean duration of surgery was 125 minutes. There were no conversions, complications, 30-day readmissions or deaths. Three patients stayed 2 days in hospital and 23 stayed overnight. One patient required esophageal dilation for persistent dysphagia. Two patients resumed medication for recurrent symptoms and 24 remained medication free. There were significant improvements in GERD-HRQL scores in all patients. Patients with CPS had no improvements in SF-36 scores, whereas patients without CPS showed significant improvement. CONCLUSION: Excellent surgical outcomes in LAR surgery can be obtained with careful patient selection at a nonacademic regional hospital. Although GERD-HRQL improved in all patients, patients with CPS showed no improvement in general health QOL scores after LAR surgery. Careful patient counselling should be employed when offering LAR surgery to patients with CPS.

Does general surgery residency prepare surgeons for community practice in British Columbia?

BACKGROUND: Preparing surgeons for clinical practice is a challenging task for postgraduate training programs across Canada. The purpose of this study was to examine whether a single surgeon entering practice was adequately prepared by comparing the type and volume of surgical procedures experienced in the last 3 years of training with that in the first year of clinical practice. METHODS: During the last 3 years of general surgery training, I logged all procedures. In practice, the Medical Services Plan (MSP) of British Columbia tracks all procedures. Using MSP remittance reports, I compiled the procedures performed in my first year of practice. I totaled the number of procedures and broke them down into categories (general, colorectal, laparoscopic, endoscopic, hepatobiliary, oncologic, pediatric, thoracic, vascular and other). I then compared residency training with community practice. RESULTS: I logged a total of 1170 procedures in the last 3 years of residency. Of these, 452 were performed during community rotations. The procedures during residency could be broken down as follows: 392 general, 18 colorectal, 242 laparoscopic, 103 endoscopic, 85 hepatobiliary, 142 oncologic, 1 pediatric, 78 thoracic, 92 vascular and 17 other. I performed a total of 1440 procedures in the first year of practice. In practice the break down was 398 general, 15 colorectal, 101 laparoscopic, 654 endoscopic, 2 hepatobiliary, 77 oncologic, 10 pediatric, 0 thoracic, 70 vascular and 113 other. CONCLUSION: On the whole, residency provided excellent preparation for clinical practice based on my experience. Areas of potential improvement included endoscopy, pediatric surgery and "other," which comprised mostly hand surgery.

Active internal re-warming using a centrifugal pump and heat exchanger following haemorrhagic shock, surgical trauma and hypothermia in a porcine model.

BACKGROUND: The centrifugal vortex blood pump (CVBP) using heparin-bonded circuitry allows re-warming of hypothermic trauma patients without anticoagulation. Study objectives were to confirm efficacy, and to characterise the physiology of CVBP re-warming in a porcine model. METHODS: Sixteen pigs were randomised to conventional or CVBP re-warming. They were bled to a mean arterial pressure of 30 mmHg and cooled to 29 degrees C. A physiological analysis was recorded during resuscitation to normo-tension and re-warming back to 37 degrees C. RESULTS: CVBP animals re-warmed significantly faster: 85.0+16.4 min versus 217.4+49.3 min (p<0.0001). Activated clotting time was significantly elevated in both groups at 29 degrees C with a marked trend to normalise faster in CVBP pigs. The peak cardiac index (CI) was significantly lower (1.14+0.68 versus 4.83+1.50 L/(min m2), while the systemic vascular resistance (SVR) was significantly higher (4239.9+1173.0 versus 1472.6+451.2 dyn x S x m2/cm5) with CVBP (p<0.001). CONCLUSION: CVBP is simple and very effective at re-warming hypothermic animals and may also reverse coagulopathy more quickly. Physiological derangements of elevated SVR and diminished CI require further study to elaborate underlying aetiology, and define optimal re-warming strategies.

Ex vivo sentinel lymph node mapping in colon cancer: improving the accuracy of pathologic staging?

BACKGROUND: A subset of patients with colon cancer staged by conventional methods have occult micrometastases and do not receive adjuvant chemotherapy. Sentinel lymph node (SLN) mapping and staining by immunohistochemistry is a technique that may identify such occult micrometastases, thereby upstaging patients with positive findings. The purpose of this study was to determine whether ex vivo SLN mapping in colon cancer could be applied successfully to patients at our institution. METHODS: Seventeen patients with intraperitoneal colon tumors undergoing resection were studied prospectively. SLNs were identified as the first blue stained node(s) after ex vivo peritumoral injection of isosulfan blue dye. Additional lymph nodes were harvested and processed in accordance with standard pathologic evaluation for colon cancer. All nodes were examined after routine hematoxylin and eosin (H&E) staining. SLNs that were negative on H&E were analyzed further by multilevel sectioning and immunohistochemistry staining using anticytokeratin monoclonal antibody. RESULTS: Of the 17 study patients, SLNs were identified in 16 (94%) cases. The SLN was the only positive node in 3 patients. An identified SLN was positive (by H&E) in all patients with associated positive non-SLN nodes. The average number of nodes retrieved per patient was 16 (range, 4-54). Overall, SLNs accurately reflected the status of the entire lymph node basin in 16 (94%) patients. Two (12%) patients with negative nodes by H&E potentially were upstaged after further SLN analysis. The negative predictive value for SLN mapping was 89%. CONCLUSIONS: The ex vivo technique of SLN mapping for colon cancer is feasible. In the current study, SLN results were concordant with non-SLNs in the majority of patients. Furthermore, this technique may have upstaged 2 (12%) patients. Whether this ultimately will affect overall survival has yet to be determined.

Examining the learning curve of laparoscopic fundoplications at an urban community hospital.

BACKGROUND: Laparoscopic fundoplication for gastroesophageal reflux disease is a procedure associated with specific complications, especially in a surgeon's early experience. The learning curve of this procedure was examined at a tertiary community institution. METHODS: A retrospective review of the first 100 cases performed at Royal Columbian Hospital was conducted. Two surgeons performed the majority of cases and routinely assisted each other. Patients were grouped chronologically with the first 50 cases defined as early institutional experience and a surgeon's first 20 cases defined as early personal experience. RESULTS: Operative time was longer in both the early institutional (117.8 versus 91.3 minutes, P < .001) and personal experience (126.8 versus 89.7 minutes, P < .001). The rate of dysphagia requiring intervention was higher during the early institutional (22% versus 4%, P = .017) but not personal experience (19% versus 8%, P = not significant). The conversion rate was 0%, reoperation rate was 1%, mean length of stay was 2.5 +/- 1.4 days, and the readmission rate was 5%; these outcomes were unaffected by the learning curve. CONCLUSIONS: There is a definable learning curve in laparoscopic fundoplication in terms of operative time. However, an acceleration of the personal learning curve in terms of dysphagia was observed with a two-surgeon collaborative approach. With careful patient selection conversion, reoperation, readmission, and complication rates equivalent to experienced centers can be achieved in the community setting early in the personal and institutional experience.

Are localized intestinal perforations distinct from necrotizing enterocolitis?

BACKGROUND/PURPOSE: Localized intestinal perforation (LP) is thought to be a distinct entity when compared with perforation associated with necrotizing enterocolitis (NEC). Studies have indicated that LP is more amenable to percutaneous drainage and associated with a better outcome. We sought to determine whether LP and NEC could be distinguished based on clinical parameters alone. METHODS: A retrospective review of 40 neonates with gastrointestinal perforations between January 1990 and May 1998 was performed. All had undergone laparotomy and had histologic specimens available for evaluation. RESULTS: Twenty-one neonates had necrotizing enterocolitis (NEC), and 19 had localized perforation (LP) based on histologic criteria. More neonates with LP were exposed to prenatal indomethacin (37% v 5%; P <.05), received intravenous dexamethasone (42% v 10%; P <.05), had umbilical artery catheters (63% v 14%; P <.05), and had a higher white blood cell (WBC) count (27.1 +/- 23.1 v 14.3 +/- 11.5; P <.05). More neonates with NEC had pneumatosis intestinalis (47% v 11%; P <.05). No significant differences existed in enteral feeding (16% LP v 38% NEC) or overall mortality rate (37% LP v 38% NEC). No statistical differences in the timing of perforation or clinical presentation were found. CONCLUSIONS: NEC and LP are difficult to distinguish based on clinical parameters alone. The authors did find associations between LP and prenatal indomethacin, intravenous dexamethasone, umbilical artery catheters, and a higher WBC count. Mortality rate and clinical outcome were nearly identical in both groups. Pneumatosis intestinalis, thought to be pathognomonic for NEC, was seen on abdominal radiograph in 2 babies with histologically proven LP.