Factors that predict 30-day readmission after bariatric surgery: experience of a publicly funded Canadian centre.

Background: Hospital readmissions after bariatric surgery can significantly increase health care costs. Rates of readmission after bariatric surgery have ranged from 0.6% to 11.3%, but the rate of complications and the factors that predict readmission have not been well characterized in Canada. The objective of this study was to characterize readmission rates and the factors that predict 30-day readmission in a Canadian centre. Methods: A retrospective study was performed on all patients who underwent bariatric surgery between 2010 and 2015 in a single Canadian centre. Procedures included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB). Prospectively collected data were extracted from an administrative database. Multivariable logistic regression analysis was performed to determine which factors predict 30-day readmission. Results: A total of 1468 patients had bariatric surgery (51.0% LRYGB, 40.5% LSG, 8.6% LAGB) during the 6-year study period, with an overall 30-day readmission rate of 7.5%. LRYGB was associated with a higher readmission rate (11.4%) than LSG (3.7%) or LAGB (1.6%). Common reasons for readmission were infection (24.8%), pain (17.4%) and nausea or vomiting (10.1%). Multivariable analysis identified 3 factors that independently predicted readmission: length of stay greater than 4 days (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.03-4.63, p = 0.042), LRYGB (OR 5.21, 95% CI 1.19-22.73, p = 0.028) and acute renal failure (OR 14.10, 95% CI 1.07-186.29, p = 0.045). Conclusion: Readmissions after bariatric surgery were most commonly caused by potentially preventable factors, such as pain, nausea or vomiting. Strategies to identify and address factors associated with readmission may reduce readmissions and health care costs after bariatric surgery in a publicly funded health care system.

Contexte: Les réadmissions hospitalières après la chirurgie bariatrique peuvent accroître significativement le coût des soins de santé. Les taux de ces réadmissions ont varié de 0,6 % à 11,3 %, mais le taux de complications et les facteurs de prédiction des réadmissions n'ont pas été bien caractérisés au Canada. L'objectif de cette étude est de caractériser les taux de réadmissions et les facteurs qui permettent de prédire une réadmission à 30 jours dans un centre canadien. Méthodes: Nous avons étudié rétrospectivement tous les cas de chirurgie bariatrique effectués entre 2010 et 2015 dans un établissement canadien. Les interventions incluaient la dérivation gastrique Roux-en-Y laparoscopique (DGRYL), la gastrectomie en manchon laparoscopique (GML) et la gastroplastie laparoscopique avec anneau ajustable (GLAA). Les données recueillies de manière prospective ont été extraites d'une base de données administrative. Nous avons procédé à une analyse de régression logistique multivariée pour déterminer quels facteurs permettaient de prédire la réadmission à 30 jours. Résultats: En tout, 1468 patients ont subi une chirurgie bariatrique (51,0 % DGRYL, 40,5 % GML et 8,6 % GLAA) durant les 6 années de l'étude, avec un taux global de réadmission à 30 jours de 7,5 %. La DGRYL a été associée un taux de réadmission plus élevé (11,4 %) que la GML (3,7 %) ou la GLAA (1,6 %). Les raisons de réadmission les plus fréquentes ont été infection (24,8 %), douleur (17,4 %) et nausées ou vomissements (10,1 %). L'analyse multivariée a permis de dégager 3 facteurs indépendants de réadmission, soit séjour de plus de 4 jours (rapport des cotes [RR] 2,18, intervalle de confiance [IC] de 95 % 1,03­4,63, p = 0,042), DGRYL (RC 5,21, IC de 95 % 1,19­22,73, p = 0,028) et insuffisance rénale aiguë (RC 14,10, IC de 95 % 1,07­186,29, p = 0,045). Conclusion: Les réadmissions après la chirurgie bariatrique ont le plus souvent été dues à des facteurs évitables, tels que douleur, nausées et vomissements. Des stratégies visant à identifier et à corriger les facteurs de réadmission pourraient réduire ces dernières et le coût des soins de santé après la chirurgie bariatrique dans un système de santé public.

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.

A day in the life of emergency general surgery in Canada: a multicentre observational study.

BACKGROUND: Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies. Despite the high volume, acuity and complexity of the patient populations served by EGS services, little has been reported about the services' structure, processes, case mix or outcomes. This study begins a national surveillance effort to define and advance surgical quality in an important and diverse surgical population. METHODS: A national cross-sectional study of EGS services was conducted during a 24-hour period in January 2017 at 14 hospitals across 7 Canadian provinces recruited through the Canadian Association of General Surgeons Acute Care Committee. Patients admitted to the EGS service, new consultations and off-service patients being followed by the EGS service during the study period were included. Patient demographic information and data on operations, procedures and complications were collected. RESULTS: Twelve sites reported resident coverage. Most services did not include trauma. Ten sites had protected operating room time. Overall, 393 patient encounters occurred during the study period (195/386 [50.5%] operative and 191/386 [49.5%] nonoperative), with a mean of 3.8 operations per service. The patient population was complex, with 136 patients (34.6%) having more than 3 comorbidities. There was a wide case mix, including gallbladder disease (69 cases [17.8%]) and appendiceal disease (31 [8.0%]) as well as complex emergencies, such as obstruction (56 [14.5%]) and perforation (23 [5.9%]). CONCLUSION: The characteristics and case mix of these Canadian EGS services are heterogeneous, but all services are busy and provide comprehensive operative and nonoperative care to acutely ill patients with high levels of comorbidity.

CONTEXTE: Les services de chirurgie générale d'urgence (CGU) gagnent en popularité au Canada en tant qu'approches systémiques aux urgences chirurgicales. Malgré le volume élevé, le caractère urgent et la complexité des populations de patients desservies en CGU, peu de rapports ont porté sur la structure, les processus, les clientèles ou les résultats de ces services. La présente étude instaure une démarche de surveillance nationale qui servira à définir et à améliorer la qualité des chirurgies destinées à cette population importante et hétérogène. MÉTHODES: Une étude transversale nationale sur les services de CGU a été réalisée sur une période de 24 heures en janvier 2017 dans 14 hôpitaux de 7 provinces canadiennes recrutés par l'entremise du comité pour les soins aigus de l'Association canadienne des chirurgiens généraux. On y a inclus les patients admis dans les services de CGU, les nouvelles consultations et les patients de l'extérieur suivis par les services de CGU pendant la période de l'étude. On a recueilli les caractéristiques démographiques des patients et les données sur les interventions, les procédures et les complications. RÉSULTATS: Douze sites ont fait état de la couverture assurée par les résidents. La plupart des services ont exclu la traumatologie. Dix sites disposaient de temps protégé au bloc opératoire. En tout, 393 rencontres avec des patients ont eu lieu pendant la période de l'étude (195/386 [50,4 %] chirurgicales, 191/386 [49,5 %] non chirurgicales), avec une moyenne de 3,8 chirurgies par service. La population regroupait des cas complexes : 136 patients (34,6 %) présentaient plus de 3 comorbidités. La clientèle était diversifiée et comprenait des cas de maladie de la vésicule biliaire (69 cas [17,8 %]) et de l'appendice (31 [8,0 %]), de même que des situations d'urgence délicates, telle qu'obstruction (56 [14,5 %]) et perforation (23 [5,9 %]). CONCLUSION: Leurs caractéristiques et leurs clientèles sont hétérogènes, mais les services de CGU sont tous achalandés et ils offrent tous des soins chirurgicaux et non chirurgicaux complets à des patients gravement malades porteurs d'importantes comorbidités.

"iBIM"--internet-based interactive modules: an easy and interesting learning tool for general surgery residents.

BACKGROUND: The increased use of information technology supports a resident- centred educational approach that promotes autonomy, flexibility and time management and helps residents to assess their competence, promoting self-awareness. We established a web-based e-learning tool to introduce general surgery residents to bariatric surgery and evaluate them to determine the most appropriate implementation strategy for Internet-based interactive modules (iBIM) in surgical teaching. METHODS: Usernames and passwords were assigned to general surgery residents at the University of Alberta. They were directed to the Obesity101 website and prompted to complete a multiple-choice precourse test. Afterwards, they were able to access the interactive modules. Residents could review the course material as often as they wanted before completing a multiple-choice postcourse test and exit survey. We used paired t tests to assess the difference between pre- and postcourse scores. RESULTS: Out of 34 residents who agreed to participate in the project, 12 completed the project (35.3%). For these 12 residents, the precourse mean score was 50 ± 17.3 and the postcourse mean score was 67 ± 14 (p = 0.020). CONCLUSION: Most residents who participated in this study recommended using the iBIMs as a study tool for bariatric surgery. Course evaluation scores suggest this novel approach was successful in transferring knowledge to surgical trainees. Further development of this tool and assessment of implementation strategies will determine how iBIM in bariatric surgery may be integrated into the curriculum.

CONTEXTE: L'utilisation croissante des technologies de l'information favorise une approche didactique centrée sur les résidents; elle favorise l'autonomie, la flexibilité et une meilleure gestion du temps, en plus d'aider les résidents à évaluer leurs compétences et à améliorer leur conscience d'eux-mêmes. Nous avons conçu un outil d'apprentissage électronique en ligne pour présenter la chirurgie bariatrique aux résidents de chirurgie générale et les évaluer, dans le but d'établir la meilleure stratégie d'application des modules de formation interactive en ligne pour l'enseignement de la chirurgie. MÉTHODES: Des noms d'utilisateurs et des mots de passe ont été assignés aux résidents de chirurgie générale de l'Université de l'Alberta. Ils ont ensuite été orientés vers le site web Obesity101 et invités à répondre à un prétest à choix multiples. Ensuite, ils ont pu accéder aux modules de formation interactive. Les résidents ont pu consulter la documentation du cours aussi souvent qu'ils le souhaitaient avant de répondre à un post-test à choix multiples et de quitter le module. Nous avons utilisé le test t d'échantillons appariés pour mesurer la différence entre les scores du prétest et du post-test. RÉSULTATS: Sur 34 résidents qui ont accepté de participer au projet, 12 l'ont mené à terme (35,3 %). Chez ces 12 résidents, le score moyen au prétest était de 50 ± 17,3 et le score moyen au post-test était de 67 ± 14 (p = 0,020). CONCLUSION: La majorité des résidents qui ont participé à cette étude ont recommandé l'utilisation des modules de formation interactive en ligne comme outil pour l'étude de la chirurgie bariatrique. Les scores d'évaluation du cours donnent à penser que cette approche novatrice a été propice au transfert des connaissances aux résidents de chirurgie. Il faudra perfectionner cet outil et en évaluer les stratégies d'application afin de déterminer de quelle façon intégrer au programme les modules de formation interactive en ligne pour la chirurgie bariatrique.

Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy.

BACKGROUND: Increasing use of gastrointestinal endoscopy, particularly for colorectal cancer screening, and increasing emphasis on health care quality, highlight the need for clearly defined, evidence-based processes to support quality improvement in endoscopy. OBJECTIVE: To identify processes and indicators of quality and safety relevant to high-quality endoscopy service delivery. METHODS: A multidisciplinary group of 35 voting participants developed recommendation statements and performance indicators. Systematic literature searches generated 50 initial statements that were revised iteratively following a modified Delphi approach using a web-based evaluation and voting tool. Statement development and evidence evaluation followed the AGREE (Appraisal of Guidelines, REsearch and Evaluation) and GRADE (Grading of Recommendations, Assessment, Development and Evaluation) guidelines. At the consensus conference, participants voted anonymously on all statements using a 6-point scale. Subsequent web-based voting evaluated recommendations for specific, individual quality indicators, safety indicators and mandatory endoscopy reporting fields. Consensus was defined a priori as agreement by 80% of participants. RESULTS: Consensus was reached on 23 recommendation statements addressing the following: ethics (statement 1: agreement 100%), facility standards and policies (statements 2 to 9: 90% to 100%), quality assurance (statements 10 to 13: 94% to 100%), training, education, competency and privileges (statements 14 to 19: 97% to 100%), endoscopy reporting standards (statements 20 and 21: 97% to 100%) and patient perceptions (statements 22 and 23: 100%). Additionally, 18 quality indicators (agreement 83% to 100%), 20 safety indicators (agreement 77% to 100%) and 23 recommended endoscopy-reporting elements (agreement 91% to 100%) were identified. DISCUSSION: The consensus process identified a clear need for high-quality clinical and outcomes research to support quality improvement in the delivery of endoscopy services. CONCLUSIONS: The guidelines support quality improvement in endoscopy by providing explicit recommendations on systematic monitoring, assessment and modification of endoscopy service delivery to yield benefits for all patients affected by the practice of gastrointestinal endoscopy.

Indicators of safety compromise in gastrointestinal endoscopy.

INTRODUCTION: The importance of quality indicators has become increasingly recognized in gastrointestinal endoscopy. Patient safety requires the identification and monitoring of occurrences associated with harm or the potential for harm. The identification of relevant indicators of safety compromise is, therefore, a critical element that is key to the effective implementation of endoscopy quality improvement programs. OBJECTIVE: To identify key indicators of safety compromise in gastrointestinal endoscopy. METHODS: The Canadian Association of Gastroenterology Safety and Quality Indicators in Endoscopy Consensus Group was formed to address issues of quality in endoscopy. A subcommittee was formed to identify key safety indicators. A systematic literature review was undertaken, and articles pertinent to safety in endoscopy were identified and reviewed. All complications and measures used to document safety were recorded. From this, a preliminary list of 16 indicators was compiled and presented to the 35-person consensus group during a three-day meeting. A revised list of 20 items was subsequently put to the consensus group for vote for inclusion on the final list of safety indicators. Items were retained only if the consensus group highly agreed on their importance. RESULTS: A total of 19 indicators of safety compromise were retained and grouped into the three following categories: medication-related - the need for CPR, use of reversal agents, hypoxia, hypotension, hypertension, sedation doses in patients older than 70 years of age, allergic reactions and laryngospasm/bronchospasm; procedure-related early - perforation, immediate postpolypectomy bleeding, need for hospital admission or transfer to emergency department from the gastroenterology unit, instrument impaction, severe persistent abdominal pain requiring evaluation proven to not be perforation; and procedure-related delayed - death within 30 days of procedure, 14-day unplanned hospitalization, 14-day unplanned contact with a health provider, gastrointestinal bleeding within 14 days of procedure, infection or symptomatic metabolic complications. CONCLUSIONS: The 19 indicators of safety compromise in endoscopy, identified by a rigorous, evidence-based consensus process, provide clear outcomes to be recorded by all facilities as part of their continuing quality improvement programs.

A population-based study of cutaneous melanoma in Alberta, Canada (1993-2002).

BACKGROUND: There is evidence to suggest that melanoma incidence rates continue to rise in Canada and the United States. OBJECTIVE: Our objective was to determine cutaneous melanoma trends from 1993 to 2002 in the province of Alberta and to compare the results to previously published provincial analyses for the decade of 1967-1976. METHODS: A retrospective study of 3479 patients with cutaneous melanoma diagnosed in Alberta between 1993 and 2002 was conducted. Estimates of relative survival compared the survival of melanoma patients with the Alberta population to derive the likelihood of surviving melanoma in the absence of other causes of death. Further comparison to published Canadian data was also conducted. RESULTS: For the period 1993-2002, the annual melanoma age-standardized incidence rates per 100,000 person-years ranged between 11.1 and 15.9 and between 9.8 and 14.1 among men and women, respectively. These rates are considerably higher than the previously reported (1976) highest Alberta incidence rates of 4.1 and 4.8 in men and women, respectively. The rates increased slightly for the period 1993-1999 with an average annual percentage change of +3.5%, but appeared to decrease for the interval 1999-2002 with an average annual percentage change of -6.4%. The majority of the tumors were less than 1.0 mm in thickness for both genders. On univariate analysis the following parameters were associated with decreasing patient survival: male gender, increasing age, head and neck tumors, Clark level of invasion, and Breslow tumor thickness. Multivariate analysis demonstrated that the strongest determinant of survival was Breslow tumor thickness. LIMITATIONS: Melanomas in-situ were not included in this study. CONCLUSIONS: Although melanoma incidence rates in Alberta are higher than previously reported, the incidence rates over the study period of 1993 to 2002 appear to have leveled and may in fact be declining over the past several years.

Learning styles of medical students, general surgery residents, and general surgeons: implications for surgical education.

BACKGROUND: Surgical education is evolving under the dual pressures of an enlarging body of knowledge required during residency and mounting work-hour restrictions. Changes in surgical residency training need to be based on available educational models and research to ensure successful training of surgeons. Experiential learning theory, developed by David Kolb, demonstrates the importance of individual learning styles in improving learning. This study helps elucidate the way in which medical students, surgical residents, and surgical faculty learn. METHODS: The Kolb Learning Style Inventory, which divides individual learning styles into Accommodating, Diverging, Converging, and Assimilating categories, was administered to the second year undergraduate medical students, general surgery resident body, and general surgery faculty at the University of Alberta. RESULTS: A total of 241 faculty, residents, and students were surveyed with an overall response rate of 73%. The predominant learning style of the medical students was assimilating and this was statistically significant (p < 0.03) from the converging learning style found in the residents and faculty. The predominant learning styles of the residents and faculty were convergent and accommodative, with no statistically significant differences between the residents and the faculty. CONCLUSIONS: We conclude that medical students have a significantly different learning style from general surgical trainees and general surgeons. This has important implications in the education of general surgery residents.

Canadian Association of University Surgeons' Annual Symposium: W(h)ither generalism(?).

This 2008 Symposium of the Canadian Association of University Surgeons (CAUS) brought together surgeons from a number of jurisdictions to discuss generalism in general surgery and its future. Dr. John Birkmeyer, the 2008 Charles Tator lecturer, started the symposium by framing the problem: the need to improve surgical outcomes, selective referral, centres of excellence, process compliance and performance feedback. Dr. John Bohnen, chair of the Royal College of Physicians and Surgeons of Canada's (RCPSC) General Surgical Specialty Committee, underscored the mismatch between the provision of care and regional Canadian patient needs. By measuring structure and process and maintaining a national dialogue, solutions to potential care inequities will be found. Dr. Bill Fitzgerald, president of the RCPSC and past president of the Canadian Association of General Surgeons (CAGS), defined the enormous breadth in the scope of practice that is available to general surgeons across Canada. He highlighted the importance of the community surgeon not only in his or her specialty but also as a vital trainer of students, residents and international medical graduates. He identified the importance of general surgery in the country's military mission. He called for a thorough re-examination of the compensation model to ensure equity and recognition of diversity. Dr. Bill Pollett, president of CAUS, identified the alternative types of practice encountered in communities of 50 000 or less. Surveys of members and trainees of the CAGS showed how much postfellowship training is done, and that whereas the perception is one of diminished quality of life and less remuneration, the nature of community general surgery makes it a highly desirable career choice. He called for focused community general surgical training to recognize the unique demands compared with urban and large city practices.

Canadian Association of University Surgeons annual symposium: Continuity of care: Toronto, Ontario, Sep. 6, 2007.

This 2007 symposium of the Canadian Association of University Surgeons brought together surgeons from a number of jurisdictions to discuss the challenges and opportunities that reduced physician work hours will bring to the care of the surgical patient. Dr. Brian Taylor, president of the association, underscored the need to find a balance between the benefits of diminished workloads/work hours and the loss of continuity of care. He opined that Canada needs to learn from our European colleagues' experience. Dr. Per-Olof Nyström, professor of surgery, presented the modern Swedish model of surgical care, which had to be developed as a consequence of the European Union's legal restrictions on the amount of time an individual surgeon may work. Sweden employs a team-based shared-care model driven by the individual surgeon's expertise rather than the "village factory" model of the multiskilled, multitasking approach of surgical care more prevalent in Canada. Dr. Chris de Gara, secretary treasurer of the association, presented the evidence base for (and against) work-hour restrictions and how well-designed systems can ensure effective continuity of care. Dr. Stewart Hamilton illustrated how one such system for the delivery of the emergency general surgical services has evolved at the University of Alberta Hospital, which demonstrated its effectiveness in providing quality surgical continuity of care. Dr. Debrah Wirtzfeld underscored the importance of trainee lifestyle and how modern Web-based technologies can ensure reduced errors with the implementation of a "sign-out" system.

Canadian consensus conference on the development of training and practice standards in advanced minimally invasive surgery: Edmonton, Alta., Jun. 1, 2007.

Despite the complexities of minimally invasive surgery (MIS), a Canadian approach to training surgeons in this field does not exist. Whereas a limited number of surgeons are fellowship-trained in the specialty, guidelines are still clearly needed to implement advanced MIS. Leaders in the field of gastrointestinal surgery and MIS attended a consensus conference where they proposed a comprehensive mentoring program that may evolve into a framework for a national mentoring and training system. Leadership and commitment from national experts to define the most appropriate template for introducing new surgical techniques into practice is required. This national framework should also provide flexibility for truly novel procedures such as natural orifice translumenal endoscopic surgery.

The Effect of Helicobacter pylori on Postoperative Outcomes in Patients Undergoing Bariatric Surgery: a Systematic Review and Meta-analysis.

Helicobacter pylori (HP) occurs in 50% of people worldwide with higher rates reported in the bariatric population. HP has been associated with adverse outcomes following bariatric surgery; however, its true impact has not yet been defined. We aimed to systematically review the effect of HP on bariatric surgery outcomes. A comprehensive literature review was conducted yielding seven studies with 255,435 patients. Meta-analysis found comparable rates of bleeding, leak, hospital length of stay, and weight loss between HP-positive and HP-negative patients. HP was, however, found to be the largest independent predictor of marginal ulceration in those undergoing RYGB, with a tenfold increase versus HP-negative patients. Overall, HP is associated with increased marginal ulceration rates, but has little impact on other bariatric surgery outcomes.

Endoscopy in Canada: Proceedings of the National Roundtable.

This 2014 roundtable discussion, hosted by the Canadian Association of General Surgeons, brought together general surgeons and gastroenterologists with expertise in endoscopy from across Canada to discuss the state of endoscopy in Canada. The focus of the roundtable was the evaluation of the competence of general surgeons at endoscopy, reviewing quality assurance parameters for high-quality endoscopy, measuring and assessing surgical resident preparedness for endoscopy practice, evaluating credentialing programs for the endosuite and predicting the future of endoscopic services in Canada. The roundtable noted several important observations. There exist inadequacies in both resident training and the assessment of competency in endoscopy. From these observations, several collaborative recommendations were then stated. These included the need for a formal and standardized system of both accreditation and training endoscopists.

A population-based study of tumor-node relationship, resection margins, and surgeon volume on gastric cancer survival.

BACKGROUND: Gastric cancer surgery literature is conflicting. Two European level I randomized controlled trials refute Asian lesser level evidence promoting more radical resections. Population-based study evidence is undefined. METHODS: Using this study design we examined the overall survival, the tumor-node relationship, margins, and surgeon volume on gastric cancer survival in a Canadian province. RESULTS: Between 1991 and 1997, 577 (71 +/- 13 years 60% male) gastric adenocarcinomas were diagnosed in Northern Alberta (population 1.7 million). Respectively, median survival in months for stage I (n = 67) was 77, stage II (n = 55) 75, stage III (n = 155) 12, stage IV (n = 235) 3, and 65 unstaged (n = 65) 4. Five-year survival for T1N0 (n = 28) was 68% versus T1N1 (n = 7) 71% (P = 0.80); for T2N0 (n = 29) 58% versus T2N1 (n = 19) 58% versus T2N3 (n = 7) 29% (P = 0.08); for T3N0 (n = 33) 57%, versus T3N1 (n = 98) 9% versus T3N2 (n = 47) 0% versus T3N3 (n = 8) 0% (P < 0.0001). Median gastrectomy survival (months) in stage III was 15 months margin negative versus 8 months margin positive versus 6 bypass and 5 for no surgery (P = 0.0004). In stage IV it was margin positive 8 versus margin negative 6 (nonsignificant), bypass 3 versus no surgery 2. Five-year survival for surgeons doing fewer than 20 gastrectomies (n = 196 patients) was 29% (median 1.4 years) versus 35% (median 2.3 years; n = 72 patients) for surgeons doing 20 or more (n = 4; P = 0.325). CONCLUSIONS: From these population data we conclude that (1) few patients present with "curable" gastric cancer, (2) node negative or small gastric cancer survival is not influenced by nodal stage, (3) positive margin resection survival is better than bypass or no surgery in stage IV but not stage III disease, and (4) surgeon volume does not appear to influence patient survival.

Learning to practice in Canada: the hidden curriculum of international medical graduates.

INTRODUCTION: There is movement of physicians internationally. In some cases, physicians are recruited from low-income countries to wealthier countries like Canada to provide medical services in underresourced communities. This needs assessment examined the clinical medicine learning challenges faced by international medical graduates (IMGs) from the perspective of both the IMGs and medical leaders (eg, Vice President-Medical for a Health Region). METHODS: Focus groups with 25 IMGs were held in 6 regional centers. Face-to-face interviews were held with 10 medical leaders. Participants were asked about the learning associated with patient management, patient referral, and investigation, for billing and insurance, and learning about new systems of care. Qualitative data were analyzed to determine how well the perspectives on learning were aligned. RESULTS: IMGs and medical leaders recognized that learning and support were needed by physicians without previous experience in Canada. They had similar lists of learning issues. Although medical leaders believed the new information was explicit, readily available, and could be learned from short explanations and lists; IMGs found that guidelines and expectations were implicit, confusing, and contradictory. There were mediating influences in the form of orientation programs, other IMGs, and "how to" lists in some cases, which helped the newcomer. DISCUSSION: There was concordance about aspects of the learning that was required between IMGs and medical leaders. There was little agreement about the approach to learning or a recognition that the learning tasks were complicated.

Complications of splenectomy.

Surgical removal of the spleen, splenectomy, is a procedure that has significantly decreased in frequency as our understanding of the infectious complications of the asplenic state increased. The full spectrum and details of splenic function, however, have yet to be fully outlined. As a result, our comprehension of the long-term consequences of splenectomy remains incomplete. We review the evidence relating to the effects of splenectomy on infection, malignancy, thrombosis, and transplantation. Perhaps the best-defined and most widely understood complication of splenectomy is the asplenic patient's susceptibility to infection. In response to this concern, novel techniques have emerged to attempt to preserve splenic function in those patients for whom surgical therapy of the spleen is necessary. The efficacy of these techniques in preserving splenic function and staving off the complications associated with splenectomy is also reviewed in this article.

Practices and attitudes of surgeons toward the prevention of surgical site infections: a provincial survey in Alberta, Canada.

We surveyed 589 surgeons in Alberta, Canada, about the prevention of surgical site infections and compared their practices to the recommendations of evidence-based guidelines. Of the 247 (42%) who responded, most (156 [63%]) were not in compliance with guideline recommendations for preoperative bathing, hair removal, antimicrobial prophylaxis, or intraoperative skin preparation (although 91 [37%] state they are following guidelines).