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1.  The evolution of trauma surgery at a high-volume Canadian centre: implications for public health, prevention, clinical care, education and recruitment 
Canadian Journal of Surgery  2015;58(1):19-23.
Trauma centres continue to evolve with respect to clinical care and their impact on public health. Despite improvements in patient outcomes, operative volumes, and therefore maintenance of surgical skills, has become a challenging issue. We sought to determine whether injury demographics and treatments at a high- volume centre changed over time.
We used the Alberta Trauma Registry to analyze all severely injured (injury severity score [ISS] ≥ 12) patient admissions over a 16-year period (1995–2011).
Of the 12 879 severely injured patients requiring admission, there was a 1.5-fold increase in the annual admission rate despite population normalization (p = 0.001). Over the 16-year interval, patients were older with a subsequent lower mortality (p = 0.001) and length of hospital stay (p = 0.007). In patients with the most severe ISS (≥ 48), there was no change in mortality (27%, p = 0.26). In 2011, falls were the most common mechanism compared with motor vehicle crashes (41% v. 23%; p < 0.001); this was a complete reversal compared with 1995 (25% v. 41%). Motorized recreational vehicle and motorcycle injuries also increased (p < 0.001). The mean number of operations performed by trauma surgeons decreased (laparotomies: 67 [17%] in 1995 v. 47 [5%] in 2011, p < 0.001). Thoracotomies and tracheostomies remained unchanged (p = 0.19).
Clinical care has improved despite an increasing overall volume of severely injured patient admissions. The number of operative interventions performed by trauma surgeons continues to decrease concurrent to a change in injury mechanisms. Despite these improvements, maintenance of technical skills among trauma surgeons has become an important issue.
PMCID: PMC4309760  PMID: 25427332
2.  Mega purchasing leads to a mega mess 
PMCID: PMC4309755  PMID: 25621907
3.  Les méga-achats à l’origine d’un méga-gaspillage 
PMCID: PMC4309756  PMID: 25621908
4.  Surgical training in Guyana: the next generation 
Canadian Journal of Surgery  2015;58(1):7-9.
The pioneering surgical training partnership between the Canadian Association of General Surgeons (CAGS) and the University of Guyana has successfully graduated 14 surgeons since 2006. The association has recruited 29 surgeons who have made 75 teaching visits to Guyana, and CAGS involvement has been critical to providing local credibility to the program, organizing the curriculum structure and developing rigorous examinations. The program is now locally sustained, with graduates leading a number of clinical hospital programs. The initial diploma qualification is being reassessed, as other specialties have introduced postgraduate Master of Medicine degree programs. Many graduates are pursuing additional training opportunities overseas, and almost all of those remaining in Guyana have returned to the tertiary centre from the regional hospitals. The program has succeeded in training surgeons and raising the standards of surgical care in Guyana, but broader health system efforts are necessary to retain surgeons in outlying regional hospitals.
PMCID: PMC4309757  PMID: 25621909
5.  Association between the appendix and the fecalith in adults 
Canadian Journal of Surgery  2015;58(1):10-14.
We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix.
We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith.
During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10–76) years. The fecalith rate was 13%–16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma.
Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the presence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.
PMCID: PMC4309758  PMID: 25427333
6.  Cause of death in patients awaiting bariatric surgery 
Canadian Journal of Surgery  2015;58(1):15-18.
Obesity is associated with increased mortality. Bariatric surgery is becoming an important treatment modality for obesity, with an associated reduction in mortality. There are few data available on the incidence and cause of death in referred patients while they are waiting for bariatric surgery.
We retrospectively examined all cases of death in patients who were referred for bariatric surgery assessment but who had not yet undergone bariatric surgery at a tertiary care centre in Halifax, Nova Scotia. The wait list comprised patients referred for surgery between March 2008 and May 2013. All cases of death were reviewed to determine age, sex, time of referral, time spent on the wait list, cause of death, comorbidities and body mass index (BMI).
Of the 1399 patients referred, 22 (1.57%) died before receiving surgery. The mean age of these patients was 62.7 (range of 32–70) years. The average time from referral to death was 21.6 months, and the average BMI was 51.5. The most frequent cause of death was cancer, followed by cardiac and infectious causes.
This study provides useful information about mortality and causes of death among patients awaiting bariatric surgery at our centre. Our results will help guide the development of a judicious system for triage in light of long wait times.
PMCID: PMC4309759  PMID: 25427334
7.  Tension plate for treatment of olecranon fractures: new surgical technique and case series study 
Canadian Journal of Surgery  2015;58(1):24-30.
Our aim was to determine the effectiveness of a new surgical technique for olecranon fractures using a tension plate (TP) designed by the operating surgeon.
We included patients with olecranon fractures treated between September 2010 and August 2013 in our study. Treatment involved a new implant and operative technique, which combined the most favourable characteristics of 2 frequently used methods, tension band wiring and plate osteosynthesis, while eliminating their shortcomings. The new method was based on the newly constructed implant.
Twenty patients participated in our study. We obtained the following functional results with our TP: median flexion 147.5° (interquartile range [IQR] 130°–155°), median extension 135°/deficit 10° (IQR 135°–145°), median pronation 90° (IQR 81.3°–90°), median supination 90° (IQR 80°–90°). Implant-related complications were noted in 1 patient, and implants were removed in 3 patients. The mean functional Mayo elbow performance score was 94.8 (range 65–100). The removal of the implant was considerably less frequent in patients operated using the new method and implant than in patients operated using conventional methods at our institution (p < 0.001). Mean duration of follow-up was 8 months.
Our TP for the treatment of olecranon fractures is safe and effective. Functional results are very good, with significantly decreased postoperative inconveniences and need to remove the implant. Less osteosynthetic material was used for TP construction, but stability was preserved.
PMCID: PMC4309761  PMID: 25427338
8.  Physician level reporting of surgical and pathology performance indicators: a regional study to assess feasibility and impact on quality 
Canadian Journal of Surgery  2015;58(1):31-40.
There is increased awareness that, to minimize variation in clinician practice and improve quality, performance reporting should be implemented at the provider level. This optimizes physician engagement and creates a sense of professional responsibility for quality and performance measurement at the individual and organizational levels.
Individual provider level reporting was implemented within a provincial health region involving 56 clinicians (general surgeons, surgical oncologists, urologists and pathologists). The 2 surgical pathology indicators chosen were colorectal cancer (CRC) lymph node retrieval rate and pT2 prostate cancer margin positivity rate. Surgical resections for all prostate and colorectal cancer performed between Jan. 1, 2011, and Mar. 30, 2012, were included. We used a pre- and postsurvey design to obtain physician perceptions and focus groups with program leadership to determine organizational impact.
Survey results showed that respondents felt the data provided in the reports were valid (67%), consistent with expectations (70%), maintained confidentiality (80%) and were not used in a punitive manner (77%). During the study period the pT2 prostate margin positivity rate decreased from 57.1% to 27.5%. For the CRC lymph node retrieval rate indicator, high baseline performance was maintained.
We developed a robust process for providing physicians with confidential, individualized surgical and pathology quality indicator reports. Our results reinforce the importance of individual physician feedback as a strategy for improving and sustaining quality in surgical and diagnostic oncology.
PMCID: PMC4309762  PMID: 25427336
9.  Increased health services use by severely obese patients undergoing emergency surgery: a retrospective cohort study 
Canadian Journal of Surgery  2015;58(1):41-47.
The aim of this study was to assess perioperative outcomes in obese patients undergoing emergency surgery.
We retrospectively reviewed the charts of all adult (> 17 yr) patients admitted to the acute care emergency surgery service at the University of Alberta Hospital between January 2009 and December 2011 who had a body mass index (BMI) of 35 or higher. Patients were divided into subgroups for analysis based on “severe” (BMI 35–39.9) and “morbid” obesity (BMI ≥ 40). Multivariate logistic regression was performed to identify predictors of in-hospital mortality after controlling for confounding factors.
Data on 111 patients (55% women, median BMI 39) were included in the final analysis. Intensive care unit (ICU) support was required for 40% of patients. Postoperative complications occurred in 42% of patients, and 31% required reoperation. Overall in-hospital mortality was 17%. Morbidly obese patients had increased rates of reoperation (40% v. 23%, p = 0.05) and increased lengths of stay compared with severely obese patients (14.5 v. 6.0 d, p = 0.09). Age (odds ratio [OR] 1.08 per increment) and preoperative ICU stay (OR 12) were significantly associated with in-hospital mortality after controlling for confounding, but BMI was not.
Obese patients requiring emergency surgery represent a complex patient population at high risk for perioperative morbidity and mortality. Greater resources are required for their care, including ICU support, repeat surgery and prolonged ICU stay. Future studies could help identify predictors of reoperation and strategies to optimize nutrition, rehabilitation and resource allocation.
PMCID: PMC4309763  PMID: 25427335
10.  The use of early immobilization in the management of acute soft-tissue injuries of the knee: results of a survey of emergency physicians, sports medicine physicians and orthopedic surgeons 
Canadian Journal of Surgery  2015;58(1):48-53.
Evidence-based guidelines on the use of immobilization in the management of common acute soft-tissue knee injuries do not exist. Our objective was to explore the practice patterns of emergency physicians (EPs), sports medicine physicians (SMPs) and orthopedic surgeons (OS) regarding the use of early immobilization in the management of these injuries.
We developed a web-based survey and sent it to all EPs, SMPs and OS in a Canadian urban centre. The survey was designed to assess the likelihood of prescribing immobilization and to evaluate factors associated with physicians from these 3 disciplines making this decision.
The overall response rate was 44 of 112 (39%): 17 of 58 (29%) EPs, 7 of 15 (47%) SMPs and 20 of 39 (51%) OS. In cases of suspected meniscus injuries, 9 (50%) EPs indicated they would prescribe immobilization, whereas no SMPs and 1 (5%) OS would immobilize (p = 0.002). For suspected anterior cruciate ligament injuries, 13 (77%) EPs, 2 (29%) SMPs and 5 (25%) OS said they would immobilize (p = 0.005). For lateral collateral ligament injuries, 9 (53%) EPs, no SMPs and 6 (32%) OS would immobilize (p = 0.04). All respondents would prescribe immobilization for a grossly unstable knee.
We found that EPs were are more likely to prescribe immobilization for certain acute soft-tissue knee injuries than SMPs and OS. The development of an evidenced-based guideline for the use of knee immobilization after acute soft-tissue injury may reduce practice variability.
PMCID: PMC4309764  PMID: 25621910
11.  Do revision total hip augments provide appropriate modularity? 
Canadian Journal of Surgery  2015;58(1):54-57.
Porous metal acetabular augments have become widely used to fill bony defects in patients undergoing revision total hip arthroplasty. The objective of this study was to determine whether the currently offered size range of the augments is appropriate for surgical needs.
We reviewed the cases of all patients at 1 centre with a porous revision shell, and when an augment was used we recorded the patient and implant characteristics.
We reviewed the cases of 281 patients, and augments were used in 24. Augment diameter was skewed toward the small end (p < 0.001), although thickness was not (p = 0.05); 21 of 24 augments were those with the smallest 3 diameters and thicknesses.
Given the sizes used, the full range of inventory provided by the manufacturer may be unnecessary, as surgeons will likely attempt a larger shell before a larger augment.
PMCID: PMC4309765  PMID: 25621911
12.  Radiographic evaluation of the ankle syndesmosis 
Canadian Journal of Surgery  2015;58(1):58-62.
Radiographic measurements to document ankle anatomy have been suggested in recent literature to be inadequate. Focus has been put on stress views and computed tomography; however, there are also issues with these modalities. An orthogonal view that could be used both statically and dynamically could help determine syndesmotic stability. The purpose of this study was to determine a parameter on a normal lateral ankle radiograph that will increase the reliability of standard radiography in diagnosing syndesmotic integrity.
Three orthopedic surgeons reviewed 80 lateral ankle radiographs. Thirty of those radiographs were reviewed on a second occasion. Rotation of the radiographs was determined by evaluating the overlap of the talar dome. Four radiographic parameters were measured 1 cm above the tibial plafond: fibular width, tibial width, and anterior and posterior tibiofibular intervals.
Seventy-two radiographs were determined by consensus to be adequate. Means and ratios were documented to determine the relationship of the fibula to the tibia. Interrater reliability ranged from moderate to near-perfect, and the intrarater reliability was documented for each ratio. The anterior tibiofibular ratio was shown to be strong to near-perfect. It demonstrates that 40% of the tibia should be seen anterior to the fibula at 1cm above the tibial plafond.
The anterior tibiofibular ratio provides an orthogonal measure for the syndesmosis that, in conjunction with those parameters previously documented, could clinically and economically improve the diagnosis of syndesmotic disruptions.
PMCID: PMC4309766  PMID: 25621912
13.  Laparoscopic right hemicolectomy with intracorporeal versus extracorporeal anastamosis: a comparison of short-term outcomes 
Canadian Journal of Surgery  2015;58(1):63-68.
There is wide variation among laparoscopic colon resection techniques, including the approach for mobilization and the extent of intracorporal vessel ligation, bowel division or anastamosis. We compared the short-term outcomes of laparoscopic right hemicolectomy (LRHC) with intracorporeal (IA) versus extracorporeal (EA) anastamosis.
We retrospectively reviewed all elective laparoscopic right hemicolectomies performed at St. Joseph’s Hospital between January 2008 and September 2009 and compared the demographic, pathologic, operative and outcome data.
Fifty LRHCs were completed during the study period: 21 IA and 29 EA. The groups were similar in age, sex, body mass index, American Society of Anesthesiologists score, previous laparotomy and preoperative invasive pathology. There was no difference between IA and EA in mean duration of surgery (170 v. 181 min, p = 0.78), estimated blood loss (14 v. 42 mL, p = 0.15), perioperative blood transfusions (5% v. 14%, p = 0.29), in-hospital morbidity (33% v. 41%, p = 0.56), out-of-hospital morbidity (19% v. 31% p = 0.34), emergency department visits (10% v. 17%, p = 0.16) or 30-day readmissions (5% v. 7%, p = 0.75). There was 1 anastamotic leak in each group and no perioperative deaths. Median length of stay was significantly shorter for IA (4 v. 5 d, p = 0.05). There were 6 extraction site hernias with EA and none with IA (p = 0.026).
Laparoscopic right hemicolectomy with IA has the advantage of a less hernia-prone Pfannenstiel extraction site, faster recovery and shorter stay in hospital EA.
PMCID: PMC4309767  PMID: 25621913
14.  Safety of a no-fast protocol for tracheotomy in critical care 
Canadian Journal of Surgery  2015;58(1):69-70.
With modern anesthesia, aspiration is an exceedingly rare complication, and we have learned that a prolonged fast can result in serious adverse effects in critically ill patients. We discuss the no-fast protocol implemented at Vancouver General Hospital in 2007 for intubated, tube-fed adult patients who underwent elective open tracheotomy.
PMCID: PMC4309768  PMID: 25621914
15.  Reviewers 2014 
Canadian Journal of Surgery  2015;58(1):71-72.
PMCID: PMC4309769
17.  Author response 
PMCID: PMC4309771  PMID: 25621916
19.  Surgery in patients with Ebola virus disease 
Canadian Journal of Surgery  2014;57(6):364-365.
PMCID: PMC4245263  PMID: 25354163
20.  Classifying outcomes of care for injured patients 
Canadian Journal of Surgery  2014;57(6):368-370.
Many trauma survivors face challenges of impaired functioning, limited activities and reduced participation. Recovery from injury after acute care, therefore, becomes an important public health issue. This commentary discusses a framework for evaluating outcomes of acute care.
PMCID: PMC4245265  PMID: 25421077
21.  “I’ve never asked one question.” Understanding the barriers among orthopedic surgery residents to screening female patients for intimate partner violence 
Canadian Journal of Surgery  2014;57(6):371-378.
Intimate partner violence (IPV) is a global public health problem. Orthopedic surgery residents may identify IPV among injured patients treated in fracture clinics. Yet, these residents face a number of barriers to recognizing and discussing IPV with patients. We sought to explore orthopedic surgery residents’ knowledge of IPV and their preparedness to screen patients for IPV in academic fracture clinic settings with a view to developing targeted IPV education and training.
We conducted focus groups with junior and intermediate residents. Discussions explored residents’ knowledge of and experiences with IPV screening and preparedness for screening and responding to IPV among orthopedic patients. Data were analyzed iteratively using an inductive approach.
Residents were aware of the issue of abuse generally, but had received no specific information or training on IPV in orthopedics. Residents did not see orthopedics faculty screen patients for IPV or advocate for screening. They did not view IPV screening or intervention as part of the orthopedic surgeon’s role. Residents’ clinical experiences emphasized time management and surgical intervention by effectively “getting through clinic” and “dealing with the surgical problem.” Communication with patients about other health issues was minimal or nonexistent.
Orthopedic surgery residents are entering a career path where IPV is well documented. They encounter cultural and structural barriers preventing the incorporation of IPV screening into their clinical and educational experiences. Hospitals and academic programs must collaborate in efforts to build capacity for sustainable IPV screening programs among these trainees.
PMCID: PMC4245266  PMID: 25421078
22.  Management and outcomes of small bowel obstruction in older adult patients: a prospective cohort study 
Canadian Journal of Surgery  2014;57(6):379-384.
The purpose of this research was to examine the morbidity, mortality and rate of recurrent bowel obstruction associated with the treatment of small bowel obstruction (SBO) in older adults.
We prospectively enrolled all patients 70 years or older with an SBO who were admitted to a tertiary care teaching centre between Jul. 1, 2011, and Sept. 30, 2012. Data regarding presentation, investigations, treatment and outcomes were collected.
Of the 104 patients admitted with an SBO, 49% were managed nonoperatively and 51% underwent surgery. Patients who underwent surgery experienced more complications (64% v. 27%, p = 0.002) and stayed in hospital longer (10 v. 3 d, p < 0.001) than patients managed nonoperatively. Nonoperative management was associated with a high rate of recurrent SBO: 31% after a median follow-up of 17 months. Of the patients managed operatively, 60% underwent immediate surgery and 40% underwent surgery after attempted nonoperative management. Patients in whom nonoperative management failed underwent surgery after a median of 2 days, and 89% underwent surgery within 5 days. The rate of bowel resection was high (29%) among those who underwent delayed surgery. Surgery after failed nonoperative management was associated with a mortality of 14% versus 3% for those who underwent immediate surgery; however, this difference was not significant.
These data suggest that some elderly patients with SBO may be waiting too long for surgery.
PMCID: PMC4245267  PMID: 25421079
23.  Self-reported practice patterns and knowledge of rectal cancer care among Canadian general surgeons 
Canadian Journal of Surgery  2014;57(6):385-390.
Our objective was to examine the knowledge and treatment decision practice patterns of Canadian surgeons who treat patients with rectal cancer.
A mail survey with 6 questions on staging investigations, management of low rectal cancer, lymph node harvest, surgical margins and use of adjuvant therapies was sent to all general surgeons in Canada. Appropriate responses to survey questions were defined a priori. We compared survey responses according to surgeon training (colorectal/surgical oncology v. others) and geographic region (Atlantic, Central, West).
The survey was sent to 2143 general surgeons; of the 1312 respondents, 703 treat patients with rectal cancer. Most surgeons responded appropriately to the questions regarding staging investigations (88%) and management of low rectal cancer (88%). Only 55% of surgeons correctly identified the recommended lymph node harvest as 12 or more nodes, 45% identified 5 cm as the recommended distal margin for upper rectal cancer, and 70% appropriately identified which patients should be referred for adjuvant therapy. Surgeons with subspecialty training were significantly more likely to provide correct responses to all of the survey questions than other surgeons. There was limited variation in responses according to geographic region. Subspecialty-trained surgeons and recent graduates were more likely to answer all of the survey questions correctly than other surgeons.
Initiatives are needed to ensure that all surgeons who treat patients with rectal cancer, regardless of training, maintain a thorough and accurate knowledge of rectal cancer treatment issues.
PMCID: PMC4245268  PMID: 25421080
24.  Can the Blaylock Risk Assessment Screening Score (BRASS) predict length of hospital stay and need for comprehensive discharge planning for patients following hip and knee replacement surgery? Predicting arthroplasty planning and stay using the BRASS 
Canadian Journal of Surgery  2014;57(6):391-397.
Knee and hip arthroplasty constitutes a large percentage of hospital elective surgical procedures. The Blaylock Risk Assessment Screening Score (BRASS) was designed to identify patients in need of discharge planning. The purpose of this study was to evaluate whether the BRASS was associated with length of stay (LOS) in hospital following elective arthroplasty.
We retrospectively reviewed the charts of individuals undergoing primary elective arthroplasty for knee or hip osteoarthritis who had a documented BRASS score.
In our study cohort of 241, both BRASS (p < 0.001) and replacement type (hip v. knee; p = 0.048) were predictive of LOS. Higher BRASS was associated with older patients (p < 0.001), higher American Society of Anesthesiologists score (p < 0.001) and longer LOS (p < 0.001). We found a specificity of 83% for a BRASS greater than 8 and a hospital stay longer than 5 days and a specificity of 92% for a BRASS greater than 10.
The BRASS represents a novel and significant predictor of LOS following elective arthroplasty. Patients with higher BRASS are more likely to stay in hospital 5 days or more and should receive pre-emptive social work consultations to facilitate timely discharge planning and hospital resources.
PMCID: PMC4245269  PMID: 25421081
25.  The location of surgical care for rural patients with rectal cancer: patterns of treatment and patient perspectives 
Canadian Journal of Surgery  2014;57(6):398-404.
Where cancer patients receive surgical care has implications on policy and planning and on patients’ satisfaction and outcomes. We conducted a population-based analysis of where rectal cancer patients undergo surgery and a qualitative analysis of rectal cancer patients’ perspectives on location of surgical care.
We reviewed Manitoba Cancer Registry data on patients with colorectal cancer (CRC) diagnosed between 2004 and 2006. We interviewed rural patients with rectal cancer regarding their preferences and the factors they considered when deciding on treatment location. Interview data were analyzed using a grounded theory approach.
From 2004 to 2006, 2086 patients received diagnoses of CRC in Manitoba (colon: 1578, rectal: 508). Among rural patients (n = 907), those with rectal cancer were more likely to undergo surgery at an urban centre than those with colon cancer (46.5% v. 28.8%, p < 0.001). Twenty rural patients with rectal cancer participated in interviews. We identified 3 major themes from the interview data: the decision-maker, treatment factors and personal factors. Participants described varying input into referral decisions, and often they did not perceive a choice regarding treatment location. Treatment factors, including surgeon factors and hospital factors, were important when considering treatment location. Personal factors, including travel, support, accommodation, finances and employment, also affected participants’ treatment experiences.
A substantial proportion of rural patients with rectal cancer undergo surgery at urban centres. The reasons are complex and only partly related to patient choice. Further studies are required to better understand cancer system access in geographically dispersed populations and to support cancer patients through the decision-making and treatment processes.
PMCID: PMC4245270  PMID: 25421082

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