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Abstract: Background: Acute care surgery (ACS) services are becoming increasingly popular. Methods: Assessment, flow, and disposition of adult ACS patients (acute, nontrauma surgical conditions) through the emergency department (ED) in a large health care system (Calgary) were prospectively analyzed. Results: Among 447 ACS ED consultations over 3 centers (70% admitted to ACS), the median wait time from the consultation request to ACS arrival was 36 minutes, and from ACS arrival to the admission request it was 91 minutes. The total ACS-dependent time was 127 minutes compared with 261 minutes for initial ED activities and 104 minutes for transfer to a hospital ward (P < .05). Forty percent of patients underwent computed tomography (CT) imaging (76% before consultation). The time to ACS consultation was 305 minutes when a CT scan was performed first. Conclusions: An ACS service results in rapid ED assessment of surgical emergencies. Patient waiting is dominated by the time before requesting ACS consultation and/or waiting for transfer to the ward. [Copyright &y& Elsevier]

The purpose of this study was to compare the rates of small bowel obstruction, anastomotic complications, and wound infections between stapled and handsewn closures of loop ileostomies. A literature search in Embase, PubMed, and Cochrane Database for Clinical Trials using search terms "closure," "loop ileostomy," and "stapled" was performed. All abstracts were reviewed to identify relevant articles, and their references were hand searched for additional studies. Six articles were identified for inclusion. Three independent reviewers extracted the following data: rates of small bowel obstruction, anastomotic complications, wound infection; length of hospital stay; and operative time. Data analysis was performed using Stata statistical software. Comparing stapled versus hand-sewn closures, there were no statistically significant differences in bowel obstruction (relative risk [RR] 0.69, 95% confidence interval [CI] 0.44 to 1.09), wound infection (RR 0.91, 95% CI 0.53 to 1.97), or anastomotic complication rates (RR 1.01, 95% CI 0.99 to 1.03). Two studies showed shorter operative times favoring stapled anastomoses. No difference was seen in length of stay. Current literature suggests no statistically significant differences between stapled and hand-sewn loop ileostomy closures, but there may be a trend favoring stapled closures with regard to lower small bowel obstruction rates and shorter operative time. [ABSTRACT FROM AUTHOR]

Abstract: Background: The long work hours in surgery may contribute to medical errors and impact patient outcomes. To date, there are no studies investigating outcomes related to fatigue in general surgery. Methods: All patients undergoing anterior resection between 1994 and 2005 at 2 university hospitals were identified. Cases were categorized as fatigued or nonfatigued and then compared with respect to complications and cancer recurrence. Results: Two hundred seventy patients underwent anterior resection during the study period. Of these, 22 were performed when the surgeon was fatigued. The fatigued and nonfatigued groups had similar preoperative characteristics. The rates of intraoperative complications (fatigued 14%, rested 18%, P = .58), major postoperative complications (fatigued 9%, rested 15%, P = .68), long-term complications (fatigued 31%, rested 31%, P = .9), and local cancer recurrence rates (fatigued 0%, rested 7%, P = .2) were not significantly different between the 2 groups. Conclusions: Surgeon fatigue did not influence outcomes after anterior resection for rectal cancer. [Copyright &y& Elsevier]

Intraabdominal adhesions develop after abdominal surgery as part of the normal healing processes that occur after damage to the peritoneum. Over the last 2 decades, much research has gone into understanding the biochemical and cellular processes that lead to adhesion formation. The early balance between fibrin deposition and degradation seems to be the critical factor in adhesion formation. Although adhesions do have some beneficial effects, they also cause significant morbidity, including adhesive small bowel obstruction, infertility and increased difficulty with reoperative surgery. Several strategies have been employed over the years to prevent adhesion formation while not interfering with wound healing. This article summarizes much of our current understanding of adhesion formation and strategies that have been employed to prevent them. [ABSTRACT FROM AUTHOR]

Uncontrollable hemorrhage during laparoscopic cholecystectomy occurs in 0.1% to 1.9% of all cases, with 88% originating from the gallbladder bed. The anatomical proximity between major branches of the middle hepatic vein and the gallbladder bed, and hence the risk of intraoperative bleeding, is unclear. CT scans of 20 random patients were retrospectively reviewed to identify the closest distance between branches of the middle hepatic vein and the gallbladder bed. The vein diameter was also recorded. Risk factors for intraoperative bleeding during laparoscopic cholecystectomy were also retrospectively reviewed. Large branches (mean diameter = 2.1 mm) of the middle hepatic vein are directly adjacent to the gallbladder bed in 10% of patients. An additional 10% of cases also possess branches within 1 mm of the gallbladder bed. Chronically scarred and contracted gallbladder disease may increase the risk of significant bleeding, requiring conversion. Twenty percent of all cases will display a large branch of the middle hepatic vein adherent or immediately adjacent to the gallbladder fossa. These patients are at increased risk for intraoperative bleeding. Furthermore, contracted gallbladders with evidence of chronic disease may be at increased risk for significant hemorrhage. [Copyright &y& Elsevier]

Background: The incidence of colorectal cancer (CRC) is increasing among young adults. We sought to report on patient and disease characteristics, treatment practice patterns and outcomes in this population. Methods: We conducted a retrospective cohort study using administrative health data from the Alberta Cancer Registry (2004–2015), including demographic and tumour characteristics, and treatment received. Outcome measures included overall and cancer-specific deaths. We used Cox regression and Kaplan–Meier curves to assess for factors associated with survival. Results: We included 18 070 patients with CRC (n = 1583 [8.8%] < 50 yr, n = 16 487 [91.2 %] ≥ 50 yr). Younger patients were more likely to present with locally advanced disease (21.0% v. 18.0%, p < 0.0001), stage III (16.4 % v. 14.6%, p < 0.0001) or metastatic (16.7% v. 13.8%, p < 0.0001) involvement. Younger patients were more likely to receive surgery (87.2% v. 80.9%, p < 0.0001), chemotherapy (59.6% v. 34.1%, p < 0.0001) or radiation therapy (49.5% v. 37.2%, p < 0.001). At 5 years, overall and cancer-specific survival was better among younger patients than older patients (30.6% v. 51.5% overall deaths, 27.5% v. 38.4% cancer-specific deaths, p < 0.0001). Conclusion: Despite higher stage and higher grade disease, young patients with CRC had more favourable oncologic outcomes than stage-matched older patients, which may be related to younger patients receiving more aggressive treatment. Further investigation should focus on optimal treatment patterns for young patients with CRC. [ABSTRACT FROM AUTHOR]

Background: The natural evolution of an acute care surgery (ACS) service is to develop disease-specific care pathways aimed at quality improvement. Our primary goal was to evaluate the implementation of an ACS pathway dedicated to suspected appendicitis on patient flow and the use of computed tomography (CT) in the emergency department (ED).Methods: All adults within a large health care system (3 hospitals) with suspected appendicitis were analyzed during our study period, which included 3 time periods: pre- and postimplementation of the disease-specific pathway and at 12-month follow-up.Results: Of the 1168 consultations for appendicitis that took place during our study period, 349 occurred preimplementation, 392 occurred postimplementation, and 427 were follow-up visits. In all, 877 (75%) patients were admitted to the ACS service. Overall, 83% of patients underwent surgery within 6 hours. The mean wait time from CT request to obtaining the CT scan decreased with pathway implementation at all sites (197 v. 143 min, p < 0.001). This improvement was sustained at 12-month followup (131 min, p < 0.001). The pathway increased the number of CTs completed in under 2 hours from 3% to 42% (p < 0.001). No decrease in the total number of CTs or the pattern of ultrasonography was noted (p = 0.42). Wait times from ED triage to surgery were shortened (665 min preimplementation, 633 min postimplementation, 631 min at the 12-month follow-up, p = 0.040).Conclusion: A clinical care pathway dedicated to suspected appendicitis can decrease times to both CT scan and surgical intervention. [ABSTRACT FROM AUTHOR]

Background: The natural evolution of an acute care surgery (ACS) service is to develop disease-specific care pathways aimed at quality improvement. Our primary goal was to evaluate the implementation of an ACS pathway dedicated to suspected appendicitis on patient flow and the use of computed tomography (CT) in the emergency department (ED). Methods: All adults within a large health care system (3 hospitals) with suspected appendicitis were analyzed during our study period, which included 3 time periods: preand postimplementation of the disease-specific pathway and at 12-month follow-up. Results: Of the 1168 consultations for appendicitis that took place during our study period, 349 occurred preimplementation, 392 occurred postimplementation, and 427 were follow-up visits. In all, 877 (75%) patients were admitted to the ACS service. Overall, 83% of patients underwent surgery within 6 hours. The mean wait time from CT request to obtaining the CT scan decreased with pathway implementation at all sites (197 v. 143 min, p < 0.001). This improvement was sustained at 12-month followup (131 min, p < 0.001). The pathway increased the number of CTs completed in under 2 hours from 3% to 42% (p < 0.001). No decrease in the total number of CTs or the pattern of ultrasonography was noted (p = 0.42). Wait times from ED triage to surgery were shortened (665 min preimplementation, 633 min postimplementation, 631 min at the 12-month follow-up, p = 0.040). Conclusion: A clinical care pathway dedicated to suspected appendicitis can decrease times to both CT scan and surgical intervention. [ABSTRACT FROM AUTHOR]

Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown.Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed.Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively.Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada. [ABSTRACT FROM AUTHOR]

Background: Multimodal treatment of colorectal liver metastases (CRLMs) relies on precise upfront assessment of resectability. Variability in the definition of resectable disease and the importance of early consultation by a liver surgeon have been reported. In this pilot study we investigated the initial resectability assessment and patterns of referral of patients with CRLMs.Methods: Surgeons and medical oncologists involved in the management of colorectal cancer at 2 academic institutions and affiliated community hospitals were surveyed. Opinions were sought regarding resectability of CRLMs and the type of initial specialty referral (hepatobiliary surgery, medical oncology, palliative care or other) in 6 clinical cases derived from actual cases of successfully performed 1- or 2-stage resection/ablation of hepatic disease. Case scenarios were selected to illustrate critical aspects of assessment of resectability, best therapeutic approaches and specialty referral. Standard statistical analyses were performed.Results: Of the 75 surgeons contacted, 64 responded (response rate 85%; 372 resectability assessments completed). Hepatic metastases were more often considered resectable by hepatobiliary surgeons than all other respondents (92% v. 57%, p < 0.001). Upfront systemic therapy was most commonly prioritized by surgical oncologists (p = 0.01). Hepatobiliary referral was still considered in 73% of "unresectable" assessments by colorectal surgeons, 59% of those by general surgeons, 57% of those by medical oncologists and 33% of those by surgical oncologists (p = 0.1).Conclusion: Assessment of resectability varied significantly between specialties, and resectability was often underestimated by nonhepatobiliary surgeons. Hepatobiliary referral was not considered in a substantial proportion of cases erroneously deemed unresectable. These disparities result largely from an imprecise understanding of modern surgical indications for resection of CRLMs. [ABSTRACT FROM AUTHOR]

Summary: Delays in the diagnosis and treatment of colon adenocarcinoma are distressing to patients and clinicians alike. Of 224 patients with resected colon cancer identified via a province-wide administrative database, 170 (76%) received their colonoscopy from a gastroenterologist (GI). Patients waited significantly longer between their colonoscopy and surgical resection when the colonoscopy was performed by a GI within an urban city (43 v. 27 d; p = 0.02). The total time from family practice referral to colonoscopy to surgical resection was shorter when a surgeon performed colonoscopy within an urban setting (105 v. 114 d; p = 0.03). In community settings, there were no significant differences in any interval, regardless of which service performed the colonoscopy. [ABSTRACT FROM AUTHOR]

Background: Evidence-Based Reviews in Surgery (EBRS) is a program developed to teach critical appraisal skills to general surgeons and residents. The purpose of this study was to assess the use of EBRS by general surgery residents across Canada and to assess residents' opinions regarding EBRS and journal clubs. Methods:We surveyed postgraduate year 2-5 residents from 15 general surgery programs. Data are presented as percentages and means. Results: A total of 231 residents (58%, mean 56% per program, range 0%-100%) responded: 172 (75%) residents indicated that they know about EBRS and that it is used in their programs. More than 75% of residents who use EBRS agreed or strongly agreed that the EBRS clinical and methodological articles and reviews are relevant. Only 55 residents (24%) indicated that they used EBRS online. Most residents (198 [86%]) attend journal clubs. The most common format is a mandatory meeting held at a special time every month with faculty members with epidemiologic - al and clinical expertise. Residents stated that EBRS articles were used exclusively (13%) or in conjunction with other articles (57%) in their journal clubs. Most re - spond ents (176 of 193 [91%]) stated that journal clubs are very or somewhat valuable to their education. Conclusion: The EBRS program is widely used among general surgery residents across Canada. Although most residents who use EBRS rate it highly, a large proportion are unaware of EBRS online features. Thus, future efforts to increase awareness of EBRS online features and increase its accessibility are required. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate the characteristics and the outcomes of primary colorectal lymphomas using a population-based registry.Methods: All cases of colorectal lymphoma diagnosed between 1980 and 2007 were identified using a provincial cancer registry. Patients meeting Dawson's criteria and having a negative bone marrow biopsy were included.Results: One hundred ten cases of colorectal lymphoma were identified, 43 met the inclusion criteria. The majority of patients was male (86%), and the median age at diagnosis was 62 (range 26-82) years. Tumors were mostly located in the cecum (51.1%) and rectum (20.9%). The 5-year overall survival rate calculated by the Kaplan-Meier method was 57%. Age under 60 was associated with a better median survival time (265 vs 54 months; p < 0.0001). The surgical treatment was associated with a better overall survival compared to medical treatment alone (110 vs 56 months; p = 0.083). Tumors located in the rectum were associated with a decreased overall survival (41 months vs 110 months; p = 0.065).Conclusions: Primary colorectal lymphoma is a rare disease. The age at diagnosis is an important predictor of outcome. Surgical resection may be associated with improved survival. Rectal lymphoma appears to be associated with a worse outcome and may warrant more aggressive therapy. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine whether morbidity and mortality in patients undergoing elective resection of colon cancer are associated with surgeon or hospital volume.Methods: Using the Nationwide Inpatient Sample database, we identified all adult patients who underwent elective resection for colon cancer as their primary procedure between 2003 and 2007. Cases were divided into three groups according to the mean number of resections performed annually by each surgeon: low volume (≤4/year), intermediate volume (5-9/year), or high volume (≥10/year). Annual hospital case-load was also categorized as low volume (≤30/year), intermediate volume (31-60/year), and high volume (≥61/year). Multiple logistic regression models were used to identify differences in morbidity and mortality.Results: A total of 54,000 patients underwent resection of colon cancer by 7,313 surgeons in 1,398 hospitals. After adjusting for important covariates including hospital volume, colon cancer resection by high-volume surgeons was an independent predictor of decreased morbidity (odds ratio [OR], 0.91; 95% CI, 0.85-0.97) and mortality (OR, 0.75; 95% CI, 0.65-0.86). Mortality was lowest among patients operated on by high-volume surgeons in high-volume hospitals (2.2% vs. 3.9%; OR, 0.56; 95% CI, 0.46-0.68).Conclusions: In patients undergoing elective resection of colon cancer, procedures done by high-volume surgeons are associated with decreased morbidity and mortality. [ABSTRACT FROM AUTHOR]

Innovation is defined as the introduction of something new, whether an idea, method or device. In this article, we describe the most important and innovative concepts and techniques that have advanced patient care within modern surgical subspecialties. We performed a systematic literature review and consulted academic subspecialty experts to evaluate recent changes in practice. The identified innovations included reduced blood loss and improved training in hepatobiliary surgery, total mesorectal excision and neoadjuvant therapies in colorectal surgery, prosthetic mesh in outpatient surgery, sentinel lymph node theory in surgical oncology, endovascular and wirebased skills in vascular and cardiovascular surgery, and the acceptance of abnormal anatomy through damage-control procedures in trauma and critical care. The common denominator among all subspecialties is an improvement in patient care manifested as a decrease in morbidity and mortality. Surgeons must continue to pursue innovative thinking, technological advances, improved training and systematic research. [ABSTRACT FROM AUTHOR]

Innovation is defined as the introduction of something new, whether an idea, method or device. In this article, we describe the most important and innovative concepts and techniques that have advanced patient care within modern surgical subspecialties. We performed a systematic literature review and consulted academic subspecialty experts to evaluate recent changes in practice. The identified innovations included reduced blood loss and improved training in hepatobiliary surgery, total mesorectal excision and neoadjuvant therapies in colorectal surgery, prosthetic mesh in outpatient surgery, sentinel lymph node theory in surgical oncology, endovascular and wire-based skills in vascular and cardiovascular surgery, and the acceptance of abnormal anatomy through damage-control procedures in trauma and critical care. The common denominator among all subspecialties is an improvement in patient care manifested as a decrease in morbidity and mortality. Surgeons must continue to pursue innovative thinking, technological advances, improved training and systematic research. [ABSTRACT FROM AUTHOR]

Summary: The benefit of a laparoscopic approach to appendectomy continues to be debated. We compared laparoscopic (LA) with open appendectomy (OA) for appendicitis in Canada using the Canadian Institute for Health Information database (2004-2008). The odds of female patients undergoing LA were 1.26 times higher than the odds of male patients, and the odds of patients with nonperforated pathology undergoing LA were 1.38 times higher than the odds of those with perforated pathology. Increasing comorbidities were associated with OA. While LA is becoming more frequent, the associated length of stay, postoperative complication rate and mortality are clearly lower than for OA. As a result, we support the continued increase in use of LA with regard to both safety and outcomes. [ABSTRACT FROM AUTHOR]