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Vol. 58, No. 6, December/décembre 2015cma.ca/cjs

Cross-specialty training in the era of competency-based education

Early experience with robotic pancreatic surgery in a Canadian institution

Functional outcomes of acutely infected knee arthroplasty: a comparison of different surgical treatment options

Is it safe to wait? The effect of surgical wait time on survival in patients with non–small cell lung cancer

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©2015 8872147 Canada Inc. Can J Surg, Vol. 58, No. 6, December 2015 361

EDITORIAL • ÉDITORIAL

364 Cross-specialty training in the era of competency-based education E.J. Harvey, V.C. McAlister

365 L’apprentissage interspécialités à l’ère de la formation basée sur les compétences E.J. Harvey, V.C. McAlister

COMMENTARY • COMMENTAIRE

367 Why Canada needs networks to provide rural surgical care, including family doctors with essential surgical skills G. Warnock, P. Miles

369 GPs with enhanced surgical skills: a questionable solution for remote surgical services C. Vinden, M.C. Ott

372 Providing mentorship support to general surgery residents: a model for structured group facilitation C. Champion, S. Bennett, D. Carver, K. El Tawil, S. Fabbro, N. Howatt, F. Noei, R. Rae, F. Haggar, A. Arnaout

RESEARCH • RECHERCHE

374 Current perioperative practice in Canadian vascular surgery M. Rockley, K. Chu, J. Bayne

378 Randomized controlled trial to investigate the effect of metal clips on early migration during stent implantation for malignant esophageal stricture C. Wang, C. Lou

383 Effects of adding Braun jejunojejunostomy to standard Whipple procedure on reduction of afferent loop syndrome — a randomized clinical trial F. Kakaei, S. Beheshtirouy, S.M.R. Nejatollahi, I. Rashidi, T. Asvadi, A. Habibzadeh, M. Oliaei-Motlagh

389 Early clinical experience with the POEM procedure for achalasia D. Hong, R. Pescarus, R. Khan, L. Ambrosini, M. Anvari, M. Cadeddu

394 Early experience with robotic pancreatic surgery in a Canadian institution S. Piedimonte, Y. Wang, S. Bergman, T. Vanounou

402 Functional outcomes of acutely infected knee arthroplasty: a comparison of different surgical treatment options I. Dzaja, J. Howard, L. Somerville, B. Lanting

408 Working toward benchmarks in orthopedic OR ef�ciency for joint replacement surgery in an academic centre P.E. Beaulé, A.A. Frombach, J.-J. Ryu

414 Is it safe to wait? The effect of surgical wait time on survival in patients with non–small cell lung cancer S. Coughlin, M. Plourde, K. Guidolin, D. Fortin, E. Frechette, R. Malthaner, R. Inculet

DISCUSSIONS IN SURGERY DISCUSSIONS EN CHIRURGIE

419 A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills N. Caron, S. Iglesias, R. Friesen, V. Berjat, N. Humber, R. Falk, M. Prins, V. Vogt Haines, B. Geller, F. Janke, R. Woollard, B. Batchelor, J. Van Bussel

Vol. 58, No. 6, December/décembre 2015canjsurg.ca

canjsurg.ca

contents-cjsdec15.indd 361 2015-11-10 10:04 AM

362 J can chir, Vol. 58, No 6, décembre 2015 ©2015 8872147 Canada Inc.

423 The importance of tailoring physicians’ trauma care training needs in rural environments P. Tarighi, J.E. Sherman, O. Mian, A.B. Nathens

426 Trends in the Canadian Surgery Forum (CSF): analysis of the CSF program over the past decade C.G. Ball, T.L. Eberle, E. Dixon, C. Boland

429 Signi�cance of CD4+ T-cell count in the management of appendicitis in patients with HIV K. Kitaoka, K. Saito, K. Tokuuye

431 A comparison of outcomes between laparoscopic and open appendectomy in Canada C. Blackmore, D. Tanyingo, G.G. Kaplan, E. Dixon, A.R. MacLean, C.G. Ball

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COEDITORS CORÉDACTEURS

Edward J. Harvey, MD, Montréal [email protected]

LCol Vivian C. McAlister, MB, London [email protected]

ASSOCIATE EDITORS RÉDACTEURS ASSOCIÉS

BASIC SCIENCE AND SURGICAL BIOLOGYIan McGilvray, MD, PhD, Toronto Timothy Daniels, MD, Toronto

BREAST SURGERYMuriel Brackstone, MD, London

CARDIOVASCULAR SURGERYMichel Carrier, MD, Montréal Michael Chu, MD, London

CRITICAL CARERaymond Kao, MD, London

ENDOCRINE SYSTEMSam Wiseman, MD, Vancouver

EVIDENCE-BASED MEDICINEMichelle Ghert, MD, Hamilton Kelly Vogt, MD, London

GASTROINTESTINAL AND COLORECTAL SURGERYMarcus Burnstein, MD, Toronto Jason Park, MD, Winnipeg

GLOBAL SURGERYDan Deckelbaum, MD, Montréal

GENERAL SURGERYDaniel Birch, MD, Edmonton Andrew Beckett, MD, Montréal

HEPATOBILIARY AND PANCREATIC SURGERYShiva Jayaraman, MD, Toronto

MEDICAL EDUCATIONCarol Hutchison, MD, Calgary

MILITARY MEDICINEHomer Tien, MD, Toronto Carlos J. Rodriguez, MD, Bethesda

ORTHOPEDIC FOOT AND ANKLE SURGERYKarl-André Lalonde, MD, Ottawa

ORTHOPEDIC SURGERYGraham Elder, MD, Sault Ste. Marie

PEDIATRIC SURGERY, GENERALVacant

PEDIATRIC SURGERY, ORTHOPEDICJames G. Wright, MD, MPh, Toronto

SPINAL SURGERYRaja Rampersaud, MD, Toronto

SPORTS MEDICINEPaul Martineau, MD, Montréal

SURGICAL ONCOLOGYGeoff Porter, MD, Halifax

SURGICAL ONCOLOGY, MUSCULOSKELETALFrank O’Dea, MD, St. John’s

SURGICAL ONCOLOGY, SOFT TISSUEChris de Gara, MB MS, Edmonton

THORACIC SURGERYJohn Yee, MD, Vancouver Richard Malthaner, MD, London

TRAUMA SURGERY, ORTHOPEDICWilliam Dust, MD, Saskatoon

TRAUMA SURGERY, SOFT TISSUEMary vanWijngaarden-Stephens, MD, Edmonton Morad Hameed, MD, Vancouver Chad Ball, MD, Calgary

VASCULAR SURGERYKent Mackenzie, MD, Montréal Tom Forbes, MD, Toronto

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The Canadian Journal of Surgery aims to contribute to the effective continuing medical education of Canadian surgical specialists and to provide surgeons with an effective vehicle for the dissemination of observations in the areas of clinical, basic science and education research.Readers can �nd CJS online at canjsurg.ca.Submission of new manuscripts can be made at http://mc.manuscriptcentral.com/cjs.

Le Journal canadian de chirurgie vise à dispenser une éducation médicale continue ef�cace aux spécialistes en chirurgie au Canada, et fournir aux chirurgiens un mécanisme ef�cace pour diffuser les constatations de la recherche clinique, fondamentale et éducative.Les lecteurs trouveront en direct le JCC à l’adresse canjsurg.ca.Nous favorisons l’envoi électronique de manuscrits. Veuillez visiter le http://mc.manuscriptcentral.com/cjs.

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EDITORIAL • ÉDITORIAL

Cross-specialty training in the era of competency-based education

A n art ic le discussing a proposed curriculum to provide surgical training to family phys-icians is included in this issue of the journal.1

We decided to publish it with accompanying com-mentaries for and against the proposal in order to facilitate an informed debate. The argument for enhancing the surgical skills of family physicians is that they could provide surgical care for patients in remote locations, where surgeons may not be based.2 Those against the proposal question its premise; patients in remote areas have remarkably good access to surgical care and they expect the same standard of care as patients elsewhere.3

The proposal comes at a time when specialty train-ing is undergoing change. Rather than designing a training program as a time-based process for the sequential acquisition of knowledge and skill, it is suggested that progression of surgical training should depend on the acquisition of defined competencies. The Royal College of Physicians and Surgeons of Canada has given this transformation the name “com-petence by design” (CBD). While CBD implementa-tion currently deals with postgraduate medical educa-tion (residency), the intention is to include the postcertification career training currently referred to as “continuing professional development” (CPD). One promised aspect of CBD is that it will permit surgeons to tailor their education to fit the practice required in their particular situations. Some surgeons will restrict their practices to areas of special interest (e.g., arthroplasty, hepatobiliary surgery); others will undertake cross-specialty training to expand their competencies (e.g., cesarian section performed by general surgeons). Where then does this proposal to train family physicians to undertake major surgery fit in the era of CBD?

Competence by design removes the element of time but does not alter the other fundamentals of training. All course modules have 4 elements: pre-requi sites, a learning phase, testing and mainte-nance of competence. Currently, the prerequisites for a trainee to undertake advanced surgical training is successful completion of the Principles of Surgery (POS) course and examination. While some credit should be given to certified family physicians, the

proposal would need to include additional training and testing in the fundamentals of surgery to meet the validated prerequisite standard. Competence by design will accommodate a practising surgeon learn-ing a new procedure where established surgical skills facilitate the acquisition of new skills. On the other hand, there is no reason to believe that non-surgeons, even if they have completed POS, would become competent more quickly than residents in training. If this is true, the curriculum for enhanced surgical skills cannot be completed within a year. More likely it would take the same effort and time as a conventional surgical training program — with-out the determined checks and balances of a certi-f ied training program. Patients and regulatory authorities expect physicians with surgical privileges to have passed standard tests of competence. Test-ing of cross-specialty competencies should remain within the responsibility of the subspecialty. Test-ing the wide range of competencies proposed in this curriculum will be logistically difficult. Training and testing within the t ime frame proposed is impossible. Finally, maintenance of competence has 3 elements: practice of the specific skill, practice of related skills and CPD. The premise of the proposal is that insufficient volumes of work are available in remote areas to maintain conventionally trained surgeons. In this situation, the family physician will be unable to maintain competence by practice of the specific or related skills and will have to spend an inordinate amount of time undertaking course-based CPD.

Provision of surgical services in a country as large as Canada requires collaboration between several levels of government, hospital authorities and several medical specialties. While the lack of a surgeon is often cited as the reason why a patient has to be transferred, the true logistical evaluation is always more complex. Surgeons who undertake care have to be prepared to deal with unexpected, dif�cult intraoperative �ndings and com-plex postoperative courses. Adages such as “preparing for the worst is better than hoping for the best” and “the last thing a surgeon learns is when not to operate” have stood the test of time. Good care of residents of remote areas must include close collaboration and

See the related commentaries by Warnock and Miles (p. 367) and Vinden and Ott (p. 369) and the discussion paper by Caron and colleagues (p. 419)

edit-december.indd 364 2015-11-10 10:42 AM


shared care with their family physician. This requires enhancement of skills over those practised by the urban family physician. It is unlikely that such enhancement would usefully include the addition of major surgery. The curriculum proposed for enhanced surgical skills of a family physician actually describes that of a generalist general surgeon.4 The authors of the curriculum pro-posal have identi�ed a perceived need for surgery in underserviced areas of Canada. Simple dismissal of the proposal will not resolve the concern. The solution will require multilevel discussions about the roles of gener-alist general surgeons and family physicians with enhanced skills (general practitioners) in an era where super-specialization is threatening care in less popu-lated districts.

Edward J. Harvey, MD; Vivian C. McAlister, MDCoeditors, Canadian Journal of SurgeryCompeting interests: E.J. Harvey is the Chief Medical Of�cer of Greybox Healthcare (Montréal) and Chairman of the Board of NXT-Sens Inc. (Montréal). None declared for V.C. McAlister.

DOI: 10.1503/cjs.015515

References: 1. Caron N, Iglesias S, Friesen R, et al. A proposal for the curriculum

and evaluation for training rural family physicians in enhanced surgi-cal skills. Can J Surg 2015;58:419-22.

2. Warnock G, Miles P. Why Canada needs networks to provide rural surgical care, including family doctors with essential surgical skills. Can J Surg 2015;58:367-8.

3. Vinden C, Ott MC. GPs with enhanced surgical skills: a questionable solution for remote surgical services Can J Surg 2015;58:369-71.

4. Webber EM, McAlister VC, Gorman L, et al. The past and future of the generalist general surgeon. Can J Surg 2014;57:6-7.

L’apprentissage interspécialités à l’ère de la formation basée sur les compétences

V ous pourrez lire dans ce numéro un article au sujet d’une proposition de programme de forma-tion en chirurgie à l’intention des médecins de

famille1. Nous avons décidé de le publié avec des com-mentaires connexes pour et contre la proposition en vue de favoriser un débat éclairé. Les tenants de la proposi-tion sont d’avis qu’en améliorant les compétences chirurgicales des médecins de famille, on augmente la possibilité d’offrir des soins chirurgicaux aux patients dans les régions éloignées où il pourrait ne pas y avoir de chirurgiens2. Les opposants doutent de la prémisse de la proposition, arguant que les patients des régions éloignées ont un excellent accès aux soins chirurgicaux et s’attendent à recevoir des soins de la même qualité que les patients d’ailleurs3.

Cette proposition survient à un moment où la forma-tion spécialisée est en pleine mutation. Au lieu de conce-voir un programme de formation comme processus basé sur le temps pour l’acquisition séquentielle de connais-sances et de compétences, on suggère que la progression de la formation en chirurgie soit plutôt fondée sur l’acquisition de compétences dé�nies. Le Collège royal des médecins et chirurgiens du Canada a donné à cette transformation l’appellation de « compétence par con-ception ». Alors que la version actuelle de l’initiative de la compétence par conception s’applique à la formation médicale postdoctorale (résidence), on compte y inclure

la formation postcerti�cation qui porte actuellement la désignation de « développement professionnel continu » (DPC). La compétence par conception permettra entre autres aux chirurgiens de personnaliser leur formation en fonction des exigences de pratique de leurs situations particulières. Certains chirurgiens limiteront leur pra-tique à des secteurs d’intérêt spécialisé (p. ex., arthroplas-tie ou chirurgie hépatobiliaire); d’autres suivront une formation interspécialité a�n d’élargir leurs compétences (p. ex., césarienne effectuée par des chirurgiens généraux). Où donc, à l’ère de la compétence par con-ception, s’inscrit cette proposition visant à former les médecins de famille pour leur permettre d’effectuer des chirurgies lourdes?

La compétence par conception supprime l’élément de temps, sans modi�er les autres éléments fondamentaux de la formation. Les modules de cours comportent tous 4 éléments : prérequis, phase d’apprentissage, examens et maintien des compétences. Actuellement, les prérequis pour qu’un stagiaire suive une formation chirurgicale avancée sont la réussite des cours et des examens portant sur les principes de chirurgie. Il faudrait accorder cer-tains crédits aux médecins de famille certi�és, mais la proposition devrait inclure une formation supplémen-taire ainsi que des examens portant sur les principes fon-damentaux de la chirurgie a�n de répondre à la norme validée des prérequis. La compétence par conception

Voir les commentaires connexes (en anglais) de Warnock et Miles (p. 367) et de Vinden et Ott (p. 369) ainsi que la discussion en chirurgie (en anglais) de Caron et collaborateurs (p. 419)

EDITORIAL


366 J can chir, Vol. 58, No 6, décembre 2015

pourra s’appliquer à un chirurgien en exercice qui apprend une nouvelle intervention : les compétences chirurgicales établies faciliteront l’acquisition des nou-velles compétences. D’autre part, il n’y a aucune raison de croire que les médecins non-chirurgiens — même s’ils ont terminé leur formation sur les principes fondamen-taux de la chirurgie — deviendront compétents plus ra pidement que les résidents en formation, auquel cas le programme d’acquisition de compétences chirurgicales avancée ne peut être terminé en 1 an. Il est plus probable qu’il nécessitera autant d’efforts et de temps qu’un pro-gramme classique de formation en chirurgie — sans les mécanismes de contrôle déterminés d’un programme de formation agréé. Les patients et les organismes de régle-mentation s’attendront à ce que les médecins qui ont des privilèges chirurgicaux aient réussi les examens normali-sés de compétences. La responsabilité des examens sur les compétences interspécialités devrait continuer d’in-comber à la surspécialité. Il sera dif�cile sur le plan logis-tique de tester la large gamme de compétences que ce programme propose. Il sera presque certainement impossible de dispenser la formation et de faire passer les examens selon le calendrier proposé. En�n, le maintien des compétences comporte 3 éléments : la pratique de la compétence particulière, la pratique des compétences connexes et le développement professionnel continu. La proposition se fonde sur une prémisse, soit que les régions éloignées offrent un volume insuf�sant de travail pour garder sur place des chirurgiens ayant reçu une for-mation classique. Or, dans une telle situation, le médecin de famille sera incapable de maintenir sa compétence par la pratique de la compétence particulière ou des compé-tences connexes. Il devra par ailleurs consacrer une quantité excessive de temps à suivre des cours pour son développement professionnel continu.

La prestation de services de chirurgie dans un pays aussi vaste que le Canada exige une collaboration entre plusieurs ordres de gouvernement, les administrations hospitalières et plusieurs spécialités médicales. Bien que l’absence d’un chirurgien soit souvent citée pour justi-fier le transfert d’un patient, la véritable évaluation logistique est toujours plus complexe. Les chirurgiens qui fournissent des soins doivent être prêts à faire face à des constatations intraopératoires inattendues et dif�-

ciles et à des développements postopératoires com-plexes. Des adages tels que « se préparer au pire est mieux qu’espérer le meilleur » et « la dernière chose qu’un chirurgien apprend est quand ne pas opérer » ont résisté à l’épreuve du temps. La prestation de bons soins aux habitants des régions éloignées doit reposer sur une étroite collaboration et le partage des soins avec les médecins de famille des patients. À cette �n, les méde-cins de ces régions doivent acquérir des compétences supplémentaires par rapport à celles dont ont besoin les médecins de famille en milieu urbain. Or, il est peu probable qu’il leur soit utile d’acquérir les compétences nécessaires pour la pratique de chirurgies lourdes. Le programme proposé pour l’acquisition par un médecin de famille de compétences chirurgicales avancée cor-respond en fait à la formation d’un chirurgien généra-liste4. Les auteurs du programme de formation proposé ont déterminé qu’il y avait un besoin perçu de compé-tences chirurgicales dans les régions mal desservies du Canada. Le simple rejet de la proposition ne résoudra pas le problème. Pour trouver une solution, il faudra tenir des discussions à plusieurs niveaux sur les rôles des chirurgiens généraux et des médecins de famille ayant des compétences avancée (omnipraticiens), à une époque où la « super-spécialisation » menace les soins dans les régions les moins peuplées.

Edward J. Harvey, MD; Vivian C. McAlister, MD

Corédacteurs, Journal canadien de chirurgie

Intérêts concurrents: E.J. Harvey est médecin hygiéniste en chef de Greybox Healthcare (Montréal) et président du Conseil d’administration de NXTSens Inc. (Montréal). Aucun déclaré pour V.C. McAlister.

DOI: 10.1503/cjs.016015

References:

1. Caron N, Iglesias S, Friesen R, et al. A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills. Can J Surg 2015;58:419-22.

2. Warnock G, Miles P, et al. Why Canada needs networks to provide rural surgical care, including family doctors with essential surgical skills. Can J Surg 2015;58:367-8.

3. Vinden C, Ott MC. GPs with enhanced surgical skills: a questionable solution for remote surgical services Can J Surg 2015;58:369-71.

4. Webber EM, McAlister VC, Gorman L, et al. The past and future of the generalist general surgeon. Can J Surg 2014;57:6-7.

ÉDITORIAL




Why Canada needs networks to provide rural surgical care, including family doctors with essential surgical skills

T wo decades ago, a crisis was identi�ed in recruiting and retaining spe-cialist surgeons in rural communities throughout Canada.1 Since then, many communities with more than 5000 but less than 15 000 people

have closed their local maternity and surgical service, leaving residents with hours of travel to larger centres.2 This shortfall has displaced risks and socio-economic burdens of travel onto rural communities, shrunk capacity for local operative maternity care, degraded emergency care of bleeding and injured patients, and withered surgical infrastructure. These scenarios have prompted a rethink of ways to help remote communities sustain expertise in surgical care. A Taskforce on the Future of General Surgery in Canada validated con-cerns of the Canadian Association of General Surgeons (CAGS) about short-falls in the preparation of rural general surgical specialists.3 A new curriculum is proposed, but it will take a decade to prepare new specialists, and it is unclear if these graduates can be enticed to work in isolated communities where they are susceptible to burnout.

A model of care that has kept lights on in some rural surgical programs is a collaboration of surgical specialists working together with family practi-tioners who have enhanced surgical skills (FPESS). Their patients have continued to receive high-quality care drawing upon an evidence-base con-�rming safety and ef�cacy of rural surgical and maternity care close to patients’ homes.2

A novel multistakeholder joint position paper developed with the col-laboration of the Rural Committee of CAGS and endorsed by its executive presents an enlightened framework for high-quality rural surgical care.4 Built on the principle of a collaborative network, it transcends a static description of geographic positioning of physical and human resources by introducing a dynamic collaborating community of providers of surgical practice, including rural FPESS, surgical specialists, anesthesiologists, nurses, laboratory personnel and transport staff. The network carries a covenant that providers in all disciplines collectively share the responsibil-ity of high-quality surgical care seamlessly provided by the right surgical specialist or generalist team at the right time with the right equipment and

Garth Warnock, MD, MSc Peter Miles, MEd, MB

Accepted for publication Oct. 26, 2015

See also the editorial on p. 364, the com-mentary by Vinden and Ott on p. 369, and the discussino paper by Caron and colleagues on p. 419

Correspondence to: G. Warnock University of British Columbia Department of Surgery 3100 – 950 West 10th Avenue Vancouver BC V5Z 1M9 [email protected]

DOI: 10.1503/cjs.014715

Time is long overdue for action to improve rural surgical services in Canada. In this issue of CJS, a proposed curriculum for the provision of enhanced surgical skills (ESS) to rural family physicians offers an opportunity to fortify a seamless network of high-quality surgical care for rural Canada. It is sup-ported and enhanced by the best available evidence and measured advice from specialists and generalists alike. Publication of this curriculum proposal provides for essential dialogue with general surgeons. We discuss why we must play an active role in the development, teaching and evaluation of ESS, or we will have minimal in�uence and limited grounds on which to criticize its outcome or celebrate the opportunity of success it promises.

SUMMARY

rural-warnock.indd 367 2015-11-10 9:59 AM

COMMENTAIRE


in the right place for the right patient. The model wel-comes leadership from general and obstetrical surgeons to attract graduating general surgical residents and locum surgeons to remote communities while promot-ing mentorship between specialists and family phys-icians. It pushes care beyond scheduled surgery to accommodate realities of providing surgery for trauma, emergency operative delivery and surgical emergencies that occur 24/7.

This issue of CJS presents a proposed curriculum and evaluation framework to prepare family practitioners who acquire ESS within the network model.5 It de�nes thoughtful care for essential and emergent surgical prob-lems in the nonpregnant and pregnant abdomen as well as nonabdominal emergencies. It is directed toward rural physicians — not those who work downtown. Several aspects of this proposal merit scrutiny. First, can family practitioners acquire the skills identi�ed within a more abbreviated period of training compared with surgical specialists? A compelling argument in support is that ESS trainees are exposed to the realities of rural medi-cine for 3 or more years, acquiring astute judgment of when and when not to offer surgical management re motely. The curriculum tailors their experience to manage diverse causes of right lower quadrant pain, including respect for the hostile peritoneal cavity. The capable family physician with laparoscopy skills can apply careful assessment and treatment without compro-mising care. Generalists who obtain cross-skills in body cavities, such as the pelvis (cesarean section), oropharynx (surgical airways) and the gastrointestinal tract (endos-copy), may deal confidently with categories of emer-gency identi�ed in the curriculum. This preserves a col-lective experience of rural specialist surgeons who have long worked shoulder to shoulder with rural family phys-icians trained in similar programs in anesthesiology and operative delivery within a culture of patient safety. This proposal offers potential for measured, reported and examined outcomes going forward. Differences of opin-ion we might hold represent testable hypotheses to be evaluated within a networked, continuous quality improvement process.

An overarching concern is whether the proposed cur-riculum might degrade quality surgical care in rural Can-ada. Abundant evidence presented in the curriculum pub-lication supports the contrary, as demonstrated by the research literature on high-quality maternity anesthesia

and surgical care, including operative delivery, by family practitioners in rural centres.5 But we can do better. Building upon the network concept, there is already evi-dence that multiple surgical communities in Canada, large and small alike, such as the Surgical Quality Assur-ance Network of British Columbia, have examined their outcomes by peer review with the American College of Surgeons’ National Surgical Quality Improvement Pro-gram. Obstetrical outcomes are being tracked through the Managing Obstetrical Risk Ef�ciently in Obstetrics Program in Alberta, a comprehensive performance improvement initiative that creates a culture of patient safety in obstetrical units.4 Networked urban and rural surgical programs should likewise aspire to measure, report and examine the quality of surgical care regardless of whether patients receive care close to home or whether they are transferred to urban centres.

Might the proposed curriculum educate practitioners who become undisciplined, unaccountable “cowboys”? This is a risk for all disciplines, enabled by the silos in which we often work. We recommend that networks replace our present system of silos. Within the network, formal continuous quality improvement programs would hold all surgical staff accountable through common medi-cal staff bylaws that follow due process. We can then adopt a uni�ed patient-centred approach that sheds attitudes of professional condescension and tribal xenophobia.Affiliations: From the Faculty of Medicine, University of British Columbia, Vancouver, BC (Warnock); and the Department of Surgery, Queen Elizabeth II Hospital, Grande Prairie, Alta. (Miles).

Competing interests: None declared.

Contributors: Both authors contributed substantially to the concep-tion, writing and revision of this commentary and approved the �nal version for publication.

References:

1. Inglis FG. Presidential address 1994. The community general surgeon: a time for renaissance. Can J Surg 1995;38:123-9.

2. Iglesias S, Caron N. Proceedings from the Invitational Meeting on Rural Surgical Services; 2007 June 22–23; Vancouver, BC. Avail-able: http://ess.rccbc.ca/wp-content/uploads/sites/5/2014/12 /GPSSymposiumProceedings.pdf (accessed 2015 Sept. 6).

3. The future of general surgery: evolving to meet a changing practice. Ottawa (ON): Royal College of Physicians and Surgeons of Canada; 2014.

4. Iglesias S, Kornelsen J, Woollard R, et al. Joint position paper on rural surgery and operative delivery. Can J Rural Med 2015;20:129-38.

5. Caron N, Iglesias S, Friesen R, et al. A proposed curriculum and evaluation for training rural family physicians in Enhanced Surgical Skills. Can J Surg 2015;58:419-22.

rural-warnock.indd 368 2015-11-10 9:59 AM



GPs with enhanced surgical skills: a questionable solution for remote surgical services

T he Canadian College of Family Physicians recently decided to recog-nize family physicians with enhanced surgical skills (ESS) as a “Com-munity of Practice” section analogous to Family Practice Anesthesia

and Family Practice Emergency Medicine. In response, the National ESS Working Group has proposed a generic 1-year curriculum for the training and evaluation of the ESS skill set.1 This proposal is problematic on many fronts: the scope of practice is incredibly wide, the educational model is com-pletely out of sync with current trends, and the underlying premise that patients should receive surgical care from family practitioners in order to avoid travel is a questionable solution to the issue of rural health care access.

This initiative lays out an ambitious curricula through which family practi-tioners will be expected to gain competency for procedural skills in almost every surgical domain during a single additional year of training. From general sur-gery, the proposed curricula covers laparoscopy and laparotomy; hernia repair; appendectomy; and perianal presentations, including hemorrhoids. Endoscopic skills would include management of both upper and lower gastrointestinal bleeding, as well as screening and surveillance. From obstetrics and gynecology, the skill set is proposed to include operative vaginal delivery, cesarean sections, dilation and curettage, ectopic pregnancy and tubal ligation, as well as ovarian and adnexal disease and hysteroscopy. The curriculum would also cover tonsil lectomy and adenoidectomy from the �eld of otolaryngology; vasec-tomy, circumcision and management of acute testicular issues from the domain of urology; and small �aps, skin grafting, carpal tunnel release and extensor ten-don repair from plastic surgery. In addition, it is proposed that the program will include training in procedural sedation and competency in ultrasonography.

CONCERNS WITH THE PROPOSED CURRICULUM

Surgeons facile in all the proposed domains have rarely been seen since the 19th century. When one considers that many residents in focused general surgery programs still struggle with dif�cult appendices and hernias in their

Christopher Vinden, MD Michael C. Ott, MD, MSc

See also the editorial on p. 364, the commentary by Warnock and Miles on p. 367, and the discussion paper by Caron and colleagues on p. 419

Accepted for publication Nov. 3, 2015

Correspondence to: C. Vinden London Health Sciences Centre, Victoria Hospital 800 Commissioners Rd E, Rm E2-218 London ON N6A 5W9 [email protected]

DOI: 10.1503/cjs.015215

The Canadian College of Family Physicians recently decided to recognize family physicians with enhanced surgical skills (ESS) and has proposed a 1-year curriculum of surgical training. The purpose of this initiative is to bring or enhance surgical services to remote and underserviced areas. We feel that this proposed curriculum is overly ambitious and unrealistic and that it is unlikely to produce surgeons, or a system, capable of delivering high-quality surgical services. The convergence of a new training curriculum for general surgeons, coupled with the current oversupply of surgeons, provide an alter-nate pathway to meet the needs of these communities. A long-term solution will also require alternate funding models, a sophisticated and coordinated national locum service and a national review of the population and infrastruc-ture requirements necessary for both sustainable resident surgical services and surgical outreach services.

SUMMARY

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COMMENTAIRE


�fth year of residency, it seems naive to suggest that com-petency in the proposed curricula can be achieved during such a short training program. Moreover, one of the major challenges currently facing general surgical training is to ensure that residents develop competency in both open and laparoscopic domains within the 5-year training program.2 These issues are likely re�ected by the recent 44% increase in American board examination failures as well as the increasing proportion of surgical trainees who complete fellowships after residency to gain additional experience.2 To suggest that general practitioners can master these same skills in a fraction of the time is not realistic. Some evidence of this can be drawn from the fact that of the “GPs with enhanced surgical skills” currently practising in Western Canada, two-thirds also completed foreign fellowships unrecognized by the Royal College of Physicians and Surgeons of Canada (RCPSC).3 While these fellowships may not be recognized, many of these GPs likely acquired some surgical training before enroll-ment in the ESS program. The ability of this program to provide an alternate pathway that circumvents the rigours of the RCPSC certi�cation process is concerning.

Another concern is that the educational model of the proposed curriculum diverges substantially from current trends in medical education. The RCPSC established the CanMEDS roles with the vision of training clinicians who encompass all of the competencies required to ful�ll their obligations to patients.4 These competencies cannot be stripped from one another or developed in isolation. The CanMEDS roles, including the recent revision, continue to ensure that Canadian surgeons represent a broad set of competencies, not just a subset of technical skills. To distill what a surgeon represents to a community to a list of basic technical elective procedures downplays the importance of the competencies beyond the role of medical expert.

Furthermore, the RCPSC is embarking on an ambitious redesign of Canadian medical education with the introduc-tion of the Competence by Design program, which aims to promote skills beyond competency and toward eventual expertise.5 Competency-based education is founded on the principle that competencies are learned and integrated in a longitudinal manner throughout undergraduate and post-graduate training. As surgical residents progress through the stages of this program (including transition to disci-pline, foundations of discipline, core of discipline, transi-tion to practice and enhanced expertise), they mature in broad aspects of surgical care that are well beyond the sim-ple technical tasks that they would learn from completion of a procedural module. The concept of “enhanced sur-gical skills” training, as described in the ESS proposal, is the antithesis of what competency-based training repre-sents, wherein the fundamental principle is not just to mas-ter simple, straightforward cases but rather to be able to safely and competently manage complex, unexpected situa-tions. To accept minimal competency in very select pro-

ced ures is unacceptable to surgeons and the general public who expect and demand more of their physicians.

Separate from the educational issue is the fact that surgery differs drastically from general practice; surgery is almost always delivered as part of a complex team that includes anes-thesiologists, operating room nurses as well as inpatient nurs-ing and ancillary services. Surgical suites have complex infra-structure and equipment and teams that look after them. Hospital laboratory facilities and blood banks play a vital role, especially when surgeons encounter unexpected �nd-ings or complications. Radiology, particularly cross-sectional imaging and percutaneous approaches, also plays an ever increasing role in the delivery of modern, high-quality sur-gical care. All parts of the surgical team have to be function-ing well to achieve consistent, high-quality outcomes. More-over, whereas surgical teams gain skill through completion of a large volume of procedures, this is not likely to be true within general practice.3 Volume–outcome associations have been studied since the 1970s, and their effect at both the sur-geon level and at the hospital level are well established.6,7 These effects are not con�ned to high-risk or complex sur-gery, but have also been shown to impact outcomes of simple procedures, such as endoscopy8 and inguinal hernia repair.9 Even within obstetrics, it has been demonstrated that com-plications are signi�cantly greater in hospitals with low deliv-ery volumes10 and that rural mothers in Canada have a 40% higher chance of major morbidity than urban mothers.11 Although studies comparing outcomes between different specialties performing the same procedure are rare, a large Canadian study reported that rates of complications and missed colon cancers are signi�cantly higher when colonos-copy is performed by family doctors than by gastroenterol-ogists or general surgeons.12

The background information in the ESS curriculum describes the obligation to travel for care as a signi�cant bar-rier to equitable access for rural Canadians. The Canada Health Act mandates that Canadians should have “reason-able access” to insured services,13 a phrase that provides some latitude in interpretation.14 Perhaps more importantly, the Act also mandates that health care be delivered on uniform terms and conditions, a phrase that has much less latitude. For surgical care, equity in outcomes and quality should clearly take precedence over equity in travel times. Surgical outcomes last a lifetime, whereas travel times are measured in hours or minutes. Patient ideologies that place more impor-tance on the location of the procedure than on the outcome are exceedingly rare outside of obstetrics and, even within obstetrical care, only a minority of patients willingly choose to have deliveries without backup services.

The threshold population size required to allow a viable and sustainable surgical service within a rural area is a debatable number and likely a moving target. If the popu-lation is too small, either the call becomes onerous or the practice volume becomes low enough that maintenance of competence and acquisition of experience become an

gp-vinden.indd 370 2015-11-10 10:10 AM

COMMENTARY

Can J Surg, Vol. 58, No. 6, December 2015 371

issue.3 Previous generations of surgeons were willing to tackle solo practice and onerous burdens of call, which facilitated surgical services in smaller centres, but such positions are unattractive to current surgical graduates. Australia, a country with similar population density to Canada, has detailed recommendations of population requirements to maintain viable specialist practices.15 For example, for Australian orthopedic surgeons, it is recom-mended that resident rural surgical services not be pro-vided unless the service includes at least 3 surgeons and the population catchment is approximately 30 000. It is recom-mended that smaller communities be served by outreach programs rather than by a resident program. Canadian communities would be well served if similar recommenda-tions were developed, as this would provide community members and politicians with realistic expectations regard-ing viable rural surgical services.

ADDRESSING ACCESS TO SURGERY IN REMOTE AREAS

While we object to the ESS proposal, it does highlight the fact that issues regarding access to surgery in remote areas have not been adequately addressed within this country. Reasons for this are multifactorial, with the dominant his-torical explanations being a lack of available manpower and supporting infrastructure, in addition to unattractive re muneration models.3 While Canadian-trained surgeons have historically been able to �nd “more appealing posi-tions,” this situation is likely to change drastically within the next few years. Given that the number of trainees has been substantially above replacement levels for several sur-gical specialties, an oversupply of new graduates will ulti-mately result in shifts in the job market. The ESS policy will only worsen this issue, as small communities trying to attract surgeons will �nd increasing dif�culty if valuable resources are consumed by family practitioners doing easy elective procedures or endoscopy.

The other historical impediment has been a training model that did not prepare general surgeons for isolated remote practice. The RCPSC’s new competency-based training program may offer a solution to this issue by provid-ing trainees with the opportunity to acquire skills within the community setting. During the transition to practice phase of the program, surgical residents will be able to train in communities similar to those they intend to serve rather than continuing training in tertiary care teaching centres. Under-serviced communities will be better served by competent sur-geons who can deal with the simple and complex, the elective and emergent, and who have the nonprocedural-based expertise of a dedicated surgeon rather than a family practi-tioner with limited surgical skills.

While we cannot support ESS as an appropriate solu-tion for rural Canadians, we do feel that the impending manpower surplus creates considerable opportunities to

address these issues. The national strategy should frame the debate with a detailed analysis of what a rural com-mun ity can realistically expect for both resident and out-reach surgical services and then focus on mechanisms that make community practice in underserviced areas attractive to new graduates in surgical disciplines. Strategies such as changes in remuneration practices, a nationally coordin-ated long-term locum system and enhanced training in community practice during surgical training will provide rural Canadians with truly competent surgeons.Af�liations: From the Schulich School of Medicine and Dentistry, Western University, London, Ont. (Vinden, Ott).


Contributors: Both authors contributed substantially to the concep-tion, writing and revision of this commentary and approved the �nal version for publication.

References

1. Caron N, Iglesias S, Friesen R, et al. A proposed curriculum and evaluation for training rural family physicians in enhanced surgical skills. Can J Surg 2015;58:419-22.

2. Klingensmith ME, Lewis FR. General surgery residency training issues. Adv Surg 2013;47:251-70.

3. Kornelsen J, Iglesias S, Humber N, et al. The experience of GP sur-geons in Western Canada: the in�uence of interprofessional relation-ships in training and practice. J Res Interprof Pract Educ 2013;3:43-61.

4. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 framework. Frank JR (ed). Ottawa: Royal College of Physicians and Surgeons of Canada; 2005.

5. Task Force on the Future of General Surgery. The Future of General Surgery: evolving to meet a changing practice. Ottawa: Royal College of Physicians and Surgeons of Canada; 2014.

6. Urbach DR. Pledging to eliminate low-volume surgery. N Engl J Med 2015;373:1388-90.

7. Birkmeyer JD, Stukel TA, Siewers AE, et al. Surgeon volume and operative mortality in the United States. N Engl J Med 2003;349: 2117-27.

8. Chukmaitov A, Bradley CJ, Dahman B, et al. Association of polypec-tomy techniques, endoscopist volume, and facility type with colonos-copy complications. Gastrointest Endosc 2013;77:436-46.

9. Nordin P, van der Linden W. Volume of procedures and risk of recurrence after repair of groin hernia: national register study. BMJ 2008;336:934-7.

10. Kyser KL, Lu X, Santillan DA, et al. The association between hos-pital obstetrical volume and maternal postpartum complications. Am J Obstet Gynecol 2012;207:42.e1-17.

11. Canadian Institute for Health Information. Hospital births in Canada: a focus on women living in rural and remote areas. Ottawa: CIHI; 2013.

12. Bressler B, Paszat LF, Chen Z, et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterology 2007;132:96-102.

13. Health Canada. Canada Health Act: Annual report 2013-2014. Ottawa: Health Canada; 2014. HC pub 140319.

14. McNiven C, Puderer H, Janes D. Census metropolitan area and cen-sus agglomeration influenced zones (MIZ): a description of the Methodology. Geography Division Statistics Canada 2000; Catalogue no. 92F0138MIE, no. 2000-2.

15. Australian Medical Workforce Advisory Committee. Sustainable spe-cialist services: a compendium of requirements – 2004 update. Sydney: AMWAC Report; 2004.

gp-vinden.indd 371 2015-11-10 10:10 AM


Providing mentorship support to general surgery residents: a model for structured group facilitation

M entorship has been a cornerstone of surgical education since its inception and over the course of the past century has evolved beyond surgical role-modelling to a mutual relationship in which an

individual draws on past experiences to promote the personal or professional growth of another.1 Although mentorship is often thought of as occurring in a vertical, dyadic pairing between a senior staff physician and junior trainee, mentorship can also occur horizontally in a peer or group format.2

Mentorship within medicine has many recognized bene�ts, including increased career satisfaction, perceived academic success, networking, stress management, academic productivity and work–family balance for mentees.3 Mentors report increased personal satisfaction, positive relationships with resi dents and faculty members and increased opportunities for career advancement.3

While informal vertical mentorship relationships are common within sur-gical training and have high levels of trainee satisfaction, they may not pro-vide the same degree of structured outcomes and accessibility as formal men-torship programs.2 Informal mentorship relationships may self-select for outgoing and socially dominant trainees and exclude those who may be more introverted or part of a marginalized group, often visible minorities and women.2 Residents without mentors often identify the lack of a formal pro-gram as a major barrier to �nding one.4 Once established, mentorship rela-tionships in surgery are often subject to scheduling and time pressures, which may limit their impact.1,2,4

The University of Ottawa General Surgery Mentorship Program was developed in recognition of the bene�ts of mentorship in surgical training with an understanding of the barriers to providing inclusive and meaning-ful mentorship opportunities, particularly among junior trainees. The themes explored in the 8-module program were identi�ed as priority areas for junior surgical trainee development through a literature review and feedback from residents and staff surgeons within the general surgery

Caitlin Champion, MD Sean Bennett, MD David Carver, MD Karim El Tawil, MD Sarah Fabbro, MD Neil Howatt, MD Farahnaz Noei, MD Rachel Rae, MD Fatima Haggar, MPH Angel Arnaout, MD, MSc

Accepted for publication April 13, 2015

Correspondence to: A. Arnaout Division of Surgery The Ottawa Hospital, General Campus Ottawa ON K1H 8L6 [email protected]

DOI: 10.1503/cjs.004315

Mentorship is foundational to surgical training, with recognized bene�ts for both mentees and mentors. The University of Ottawa General Surgery Men-torship Program was developed as a module-based group facilitation program to support inclusive personal and professional development of junior general surgery residents. The group format provided an opportunity for both verti-cal and horizontal mentorship relationships between staff mentors and resi-dent mentees. Perceived bene�ts of program participants were evaluated at the conclusion of the first year of the program. The program was well-received by staff and resident participants and may provide a time- ef�cient and inclusive mentorship structure with the additional bene�t of peer sup-port. We review the development and implementation of the program to date and share our mentorship experience to encourage the growth of formal men-torship opportunities within general surgery training programs.

SUMMARY


mentor-champion.indd 372 2015-11-10 9:18 AM

COMMENTARY


training program (Appendix 1, available at canjsurg.ca). Modules were completed throughout the �rst 2 years of residency training and were facilitated in an informal environment by a staff physician mentor following the same cohort of residents throughout the program. The module themes included a program introduction, health and wellness, study skills, leadership styles, con�ict res-olution, team management, career development and a wrap-up session. Each module was structured around a theme and included supplemental resources for discus-sion, including a TED talk and reading from the sur-gical literature. The program provided structured guid-ance for mentors and mentees with regards to module topics, but the way in which each topic was explored and the use of supplemental resources was determined by the mentor and mentee group. The creation of a longi-tudinal structured mentorship relationship within an informal environment was intended to promote the ben-e�ts of mentorship, while also promoting the develop-ment of a peer support network.

Participation in the program was voluntary for both mentors and mentees, with all residents choosing to participate. At the conclusion of its �rst year, the impact of the mentorship program was evaluated with anony-mous participant program evaluations rating perceived bene�ts identi�ed from the mentorship literature as well as partici pants’ module-speci�c experiences and percep-tions of the overall program structure on a 5-point Likert scale. At the time of evaluation all 8 program modules had been completed across the first- and second-year resident cohorts.

Residents across both groups rated the utility of the sessions, improvements in their understanding of the issues raised in the module and the supportive environ-ment of their mentors and fellow mentees very highly. Residents rated all perceived mentorship bene�ts as neu-tral or higher as a result of the program, with the most bene�t seen in the areas of positive impact on residency life, improved collegiality and the opportunity for re�ec-tion. Residents also identi�ed the program as helping them to become stronger residents through improved motivation, improved work–life balance, increased con�-dence, improved creativity and goal setting. Residents felt encouraged to pursue independent one-on-one mentor-ship relationships at the conclusion of the program. Staff surgeon mentors also rated their perceived benefits highly, including increased collegiality with the residents, increased personal satisfaction and an opportunity to re�ect on their own practices. They felt they had made a positive impact on their mentees and that the program had positively impacted their lives, and they would con-sider participating again.

Use of the supplemental resources varied between and among the first- and second-year mentorship groups, with some participants rating them very highly

and others rating them neutrally. Beyond the variable response to the supplemental resources, all participants felt the program should continue to be offered in its current form to incoming resident cohorts over their �rst 2 years of training. With regards to mentorship in senior training years, the majority of participants rec-ommended a transition to self-selected, one-on-one mentorship relationships, but some expressed interest in an ongoing group program.

Overall, our initial program evaluation indicates that the recognized bene�ts of mentorship may be achieved in a facilitated, structured group format with high men-tor and mentee satisfaction. The program is perceived to be of bene�t to general surgery trainees during their �rst 2 years of residency, promotes inclusive mentorship opportunities for residents and may support the forma-tion of self-selected independent mentorship relation-ships at the completion of the structured program. The group format may also help alleviate time pressures on participants by providing an opportunity for longitud-inal mentorship relationships among a cohort of resi-dents developed across multiple brief sessions. Lack of mentorship opportunities and social supports within Canadian general surgery training programs have been identi�ed as potential contributors to resident burnout and attrition.5 The access to mentorship combined with increased collegiality and peer support provided by a facilitated group program may improve the training experience of general surgery residents and support their overall career development.Af�liations: From the Division of General Surgery, Department of Surgery, The Ottawa Hospital, Faculty of Medicine, University of Ottawa (Champion, Bennett, Carver, El Tawil, Fabbro, Howatt, Noei, Rae); the Department of Surgery, The Ottawa Hospital, The Ottawa Hospital Research Institute, University of Ottawa (Haggar); and the Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Ottawa (Arnaout), Ottawa, Ont.


Contributors: All authors contributed substantially to the conception, writing and revision of this commentary and approved the �nal version for publication.

References

1. Entezami P, Franzblau LE, Chung KC. Mentorship in surgical training: a systematic review. Hand (N Y) 2012;7:30-6.

2. Patel VM, Warren O, Ahmed K, et al. How can we build mentorship in surgeons of the future? ANZ J Surg 2011;81:418-24.

3. Welch JL, Jiminez HL, Walthall J, et al. The Women in Emergency Medicine Mentoring Program: an innovative approach to mentoring. J Grad Med Educ 2012;4:362-6.

4. Geltzeiler MN, Lighthall JG, Wax MK. Mentorship in otolaryngology: 10 years of experience. Otolaryngol Head Neck Surg 2013;148: 338-40.

5. Tomlinson C, LeBossiere J, Rommens K, et al. The Canadian general surgery resident: de�ning current challenges for surgical leadership. Can J Surg 2012;55:S184-90.

mentor-champion.indd 373 2015-11-10 9:18 AM


Current perioperative practice in Canadian vascular surgery

Background: The Enhanced Recovery After Surgery (ERAS) Society has set out to improve patient recovery by developing evidence-based perioperative practices. Many institutions and other specialties have begun to apply their principles with great suc-cess; however, ERAS principles focus mostly on general surgery, and their applicabil-ity to other specialties, such as vascular surgery, is less clear. We sought to investigate the current standard of perioperative care in Canadian vascular surgery by assessing surgeons’ perceptions of evidence supporting ERAS practices, identifying barriers to aligning them and identifying aspects of perioperative care that require research spe-ci�c to vascular surgery before they could be broadly applied.

Methods: We administered an online survey with 26 questions to all Canadian Soci-ety for Vascular Surgery members.

Results: Respondents varied largely in perioperative practice, most notably in the use of nasogastric tubes, Foley catheters and neck drains. Familiarity with supporting evidence was poor. Approximately half (44%) of respondents were not familiar with contrary evidence, while those who were often perceived institutional barriers to change. Finally, one-third (30%) of respondents felt that relevant evidence did not exist to support changing their practice.

Conclusion: The variability of perioperative practice in Canadian vascular surgery is likely due to multiple factors, including a lack of speci�c evidence. Further research in areas of perioperative vascular care where the current standard of practice varies most greatly may help improve recovery after vascular surgery in Canada over simply adopting existing ERAS principles.

Contexte : L’Enhanced Recovery After Surgery Society (ERAS) cherche à améliorer la convalescence des patients en mettant au point des pratiques périopératoires basées sur des données probantes. Beaucoup d’établissements et d’autres spécialités ont commencé à appliquer les principes de l’ERAS avec beaucoup de succès, mais ceux-ci visent principale-ment la chirurgie générale, et leur applicabilité à d’autres spécialités, comme la chirurgie vasculaire, est moins claire. Nous avons cherché à étudier la norme actuelle de soins péri-opératoires en chirurgie vasculaire au Canada en évaluant les perceptions qu’ont les chirurgiens des données probantes à l’appui des pratiques de l’ERAS et en cernant les obstacles à leur harmonisation et les aspects des soins périopératoires devant faire l’objet d’une recherche particulière à la chirurgie vasculaire avant qu’on puisse les généraliser.

Méthodes : Nous avons mené un sondage en ligne de 26 questions auprès de tous les membres de la Société canadienne de chirurgie vasculaire.

Résultats : La pratique périopératoire des répondants variait considérablement, sur-tout en ce qui concerne l’usage des sondes naso-gastriques, des cathéters de Foley et des drains de cou. La connaissance des données probantes à l’appui était faible. Envi-ron la moitié (44 %) des répondants ne connaissaient pas bien les données probantes allant à l’encontre de ces pratiques, et ceux qui les connaissaient percevaient souvent des obstacles institutionnels au changement. En�n, le tiers (30 %) des répondants étaient d’avis qu’aucune donnée probante pertinente ne justi�ait un changement de pratique.

Conclusion : La variabilité de la pratique périopératoire en chirurgie vasculaire au Canada est probablement attribuable à de multiples facteurs, y compris le manque de données probantes précises. Des recherches plus poussées dans les domaines des soins vasculaires périopératoires où la norme actuelle de pratique varie le plus pourraient aider à améliorer la convalescence après une chirurgie vasculaire au Canada par rap-port à la simple application des principes de l’ERAS.

Mark Rockley, BSc Kathleen Chu, BSc Jason Bayne, MD

Presented as a poster at the Canadian Society for Vascular Surgeons Annual Meeting, Sept. 13–14, 2013, Edmonton, Alta.

Accepted for publication April 7, 2015

Correspondence to: M. Rockley The Ottawa Hospital – Civic Campus Rm A-280, 1053 Carling Ave Ottawa ON K1Y 4E9 [email protected]

DOI: 10.1503/cjs.013614


current-chu.indd 374 2015-11-10 9:24 AM

RESEARCH


A growing body of evidence in multiple surgical spe-cialties suggests that the traditional perioperative care of surgical patients needs to be updated.1 As

the evidence supporting updated perioperative manage-ment builds, a gap has developed between actual practice and the established best practice from the literature. This gap is evident in a variety of common perioperative man-agement principles.2

Attempts in specialties such as general surgery have been made to create a perioperative practice that re�ects current evidence.3–5 For example, the Enhanced Recovery After Surgery (ERAS) Society was formed to aggregate various evidence–practice gaps into a “multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery.”6 The ERAS Society has pub-lished 3 speci�c guidelines for perioperative practice spe-ci�c to the practice of general surgery.7–9

Unfortunately, evidence speci�c to the perioperative man-agement of vascular surgery patients is not as well established as it is for their general surgery counterparts.1 While random-ized trials have generally supported the implementation of ERAS concepts in major vascular surgery,1,10,11 these trials were relatively small and did not speci�cally support the indi-vidual components of ERAS protocols. Some areas of peri-operative practice have been speci�cally investigated in vascu-lar surgery patients,12–15 while many other areas have yet to be individually investigated with robust studies in the vascular surgery literature. As such, these minimally examined areas of perioperative care in vascular surgery present an opportunity to establish directed investigations to guide practice.

To direct future focused investigation in vascular peri-operative management we must �rst understand the cur-rent state of practice and surgeons’ impressions of the cur-rent evidence. The primary objective of this study was to review the current standard of perioperative care in Can-adian vascular surgery. We also assessed the perceptions of evidence in perioperative care and identi�ed barriers to changing perioperative practice.

METHODS

We sent an online survey (Appendix 1, available at canjsurg .ca) to all Canadian Society for Vascular Surgery (CSVS) members, inquiring about speci�c components of periopera-tive practices. Four subsequent reminders to participate in the survey were distributed until an insigni�cant increase in response rate was achieved. Surgeons were asked to describe their perceptions of current evidence in perioperative care and the barriers that limit potential change in their practices. The survey was developed using validated research tech-niques of surveying physicians,16 and was reviewed by Uni-versity of Alberta statisticians for scienti�c consistency.

The questions in this survey were constructed using the ERAS guidelines as a framework to delineate components of perioperative practice:

Preoperative

• Clear �uids fast before surgery• Solid food fast before surgery• Preoperative use of oral bowel preparation• Use of epidural analgesia

Intraoperative

• Use of abdominal drains

Postoperative

• Use of postoperative nasogastric tubes• Foley catheter removal, regardless of epidural analgesia• Use of chewing gum

RESULTS

Of the 135 CSVS members who received the survey, 51 (38%) responded. Figure 1 shows the typical preoperative fasting instructions given to patients. The most common instruction was the traditional guideline of fasting at mid-night before surgery. Only 13% of respondents practised in line with the Cochrane Review �ndings5 at the time of our survey; however, 21% of respondents commented that there is a lack of relevant evidence in vascular sur-gery to support this guideline (Table 1).

The reported use of routine postoperative drains is displayed in Figure 2. While 96% of respondents avoid routine abdominal drainage, drains are more com-monly placed in the groin and neck. Figure 3 displays the use of Foley catheters. Although 79% of respond-ents routinely use Foley catheters while there is epi-dural analgesia, the majority of those users believe that it is safe to remove Foley catheters during epidural analgesia.

Fig. 1. Preoperative fasting instructions given by respondents to their patients.

2

77

4

17

2

49

23 26

0

10

20

30

40

50

60

70

80

90

100

Midnight before surgery

≥ 24 hours ≥ 12 hours ≥ 6 hours ≥ 2 hours

Per

cent

of

resp

onde

nts

(%)

Solid food fast

Clear uid fast


RECHERCHE


We also sought to characterize the perceived barriers to changing perioperative care (Table 1). For each of the perioperative components, the most common response was that there is “no need to change.” An average of 30% of respondents felt that there is a lack of relevant evidence to justify changing their practices. As well, there were signi�-cant institutional barriers to changing preoperative fasting timelines and postoperative Foley catheter removal.

Finally, respondents were asked to relate their practices with their understanding of current evidence (Table 2). The most common answer was that respondents were “unaware of evidence contrary” to their practices. Of those who were aware of contrary evidence, respondents were least convinced by evidence surrounding early nasogastric

tube removal and the use of postoperative chewing gum. In addition, respondents were most likely to manage Foley catheters contrary to their belief of opposing evidence.

DISCUSSION

In recent years, the awareness of perioperative research and resulting changes in practice have resulted in similar surveys in other surgical specialties.17,18 A common theme of both these previous surveys and ours is variability in the management of perioperative care. Interestingly, this vari-ability is not always con�ned to the components of peri-operative care that have minimal supporting evidence, and may be attributable to multiple external factors.

Table 1. Perceived barriers to changing perioperative practice, by perioperative component

Component

There is no need to

change (%)

Lack of relevant

evidence (%)

Lack of anesthesia support (%)

Lack of nursing

support (%)

Lack of institutional support (%)

Preoperative fasting timeline 57 21 29 14 14

Drain management 57 36 0 0 0

Nasogastric tube removal 55 33 2 5 5

Foley catheter removal 48 24 26 19 14

Chewing gum 50 36 2 5 5

Average 53 30 12 9 8

Table 2. Perceived relation of current practice with published evidence, by perioperative component

Component

Never heard of evidence contrary to my practice (%)

My practice resembles published

evidence (%)

Not convinced by evidence contrary to my practice (%)

Convinced by contrary evidence, but don’t practice

it for various reasons (%)

Preoperative fasting timeline 46 55 5 9

Drain management 44 40 7 2

Nasogastric tube removal 42 22 18 13

Foley catheter removal 40 27 7 22

Chewing gum 49 9 24 7

Average 44 31 12 11

Fig. 2. Estimated frequency of postoperative drain usage for various operative sites.

89

53

41

6

45

28

22 47

2

20

0

10

20

30

40

50

60

70

80

90

100

NeckLeg/groinAbdomen

Per

cent

of

resp

onde

nts

(%)

Never

0%–25%

25%–50%

50%–75%

75%–100%

Fig. 3. Foley catheter removal timing, demonstrating breakdown of respondents who believe Foley catheter removal is safe in patients with epidural analgesia.

41

21

38

0

10

20

30

40

50

60

70

80

90

100

Do not routinely remove Foley duringepidural analgesia in practice

Routinely remove Foley during epidural analgesia in practice

Per

cent

of

resp

onde

nts

(%)

Do not believe Foley catheters are safe to remove during epidural analgesia

Believe Foley catheters are safe to remove during epidural analgesia


RESEARCH


In our survey, the majority of respondents reported rou-tinely avoiding abdominal drainage, which may be a result of convincing evidence over the last 2 decades in general sur-gery.19 There is less evidence regarding the routine use of groin and neck drains in any surgical specialty, and the cur-rent practice is accordingly variable. In particular, the bimodal distribution of neck drain placement indicates that surgeons are con�icted about their utility. Respondents also identi�ed the management of postoperative nasogastric tubes as being supported by unconvincing evidence, which is re�ected in the variability seen in current practice. These results are contrasted by a survey of general surgeons, who use nasogastric tubes less frequently, and are supported by more robust evidence speci�c to their specialty.3,17 The use of both postoperative nasogastric tubes and nonabdominal drains are areas of perioperative management that would therefore bene�t from focused research in vascular surgery.

The lack of relevant research, however, was not the only barrier to changing perioperative management. External fac-tors, such as anesthesia, nursing and institutional protocols, were cited as barriers to changing preoperative fasting guide-lines and timing of Foley catheter removal. These barriers should not be dismissed, as more than half of the respond-ents who routinely use Foley catheters during epidural analgesia believe that it is actually safe to remove the cath-eters. Establishing focused perioperative evidence in these topics and further dissemination of existing evidence may help with advancing institutional change.

Although we have identi�ed multiple components of peri-operative practice for which there are barriers to change, many respondents reported that there is no need to change. In addition, the most prevalent barrier reported was a lack of awareness of evidence contrary to current practice. Thus, there is an opportunity to discuss the current evidence for perioperative management in vascular surgery to potentially improve patient care.

CONCLUSION

Perioperative practice in vascular surgery varies nationally, and we have identi�ed multiple trends of practice in vascular surgery that con�ict with evidence established in other sur-gical specialties. Respondents identi�ed the use of postopera-tive nasogastric tubes and nonabdominal drains as areas of limited relevant evidence in vascular surgery, which would bene�t from further investigation. In addition, surgeons per-ceive multiple external pressures that in�uence their perioper-ative management. Components most prominently affected by external pressures include preoperative fasting and postop-erative Foley catheter removal timelines. While components of ERAS may promote evidence-based practice and improve patient care in general surgery, broad implementation of a general surgery–based ERAS program in vascular surgery may have negative effects if evidence is not �rst established and accepted by vascular surgeons.

Af�liations: All authors are from the University of Alberta, Edmonton, Alta.


Contributors: M. Rockley and J. Bayne designed the study. M. Rockley acquired the data, which all authors analyzed. All authors wrote and reviewed the article and approved the �nal version for publication.

References

1. Muehling B, Schelzig H, Steffen P, et al. A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair. World J Surg 2009;33:577-85.

2. de Gara C. How evidence-based are CAGS surgeons really? Can J Surg 2007;50:90-4.

3. Verma R, Nelson RL. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2010; (3):CD004929.

4. Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel prepa-ration for elective colorectal surgery. Cochrane Database Syst Rev 2005; (1):CD001544.

5. Brady M, Kinn S, Stuart P, et al. Preoperative fasting for adults to pre-vent perioperative complications. Cochrane Database Syst Rev 2003; (4):CD004423.

6. Enhanced Recovery After Surgery Society. (2010). About ERAS. Available: www.erassociety.org/ (accessed 2014 June 1).

7. Gustafsson UO, Scott MJ, Schwenk W, et al. Guidelines for periop-erative care in elective colonic surgery: Enhanced Recovery After Sur-gery (ERAS) Society recommendations. World J Surg 2013;37:259-84.

8. Nygren J, Thacker J, Carli F, et al. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg 2013;37:285-305.

9. Lassen K, Coolsen M, Slim K, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg 2013;37:240-58.

10. Muehling BM, Ortlieb L, Oberhuber A, et al. Fast track management reduces the systemic in�ammatory response and organ failure following elective infrarenal aortic aneurysm repair. Interact Cardiovasc Thorac Surg 2011;12:784-8.

11. Renghi A, Gramaglia L, Ciarlo M, et al. [Fast track in abdominal aortic surgery]. Minerva Anestesiol 2001;67:441-6.

12. Gouëf�c Y, Rozec B, Sonnard A, et al. Evidence for early nasogastric tube removal after infrarenal aortic surgery: a randomized trial. J Vasc Surg 2005;42:654-9.

13. Friedman SG, Sowerby SA, Del Pin CA, et al. A prospective random-ized study of abdominal aortic surgery without postoperative nasogas-tric decompression. Cardiovasc Surg 1996;4:492-4.

14. McArdle GT, Price G, Lewis A, et al. Positive �uid balance is associ-ated with complications after elective open infrarenal abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2007;34:522-7.

15. McArdle GT, McAuley D, McKinley A, et al. Preliminary results of a pro-spective randomized trial of restrictive versus standard �uid regime in elec-tive open abdominal aortic aneurysm repair. Ann Surg 2009;250:28-34.

16. Flanigan TS, McFarlane E, Cook S. Conducting survey research among physicians and other medical professionals: a review of current literature. ASA Proceedings of the Section on Survey Research Methods. 2008:4136–47.

17. Kahokher A, Robertson P, Sammour T, et al. Perioperative care: a sur-vey of New Zealand and Australian colorectal surgeons. Colorectal Dis 2011;13:1308-13.

18. Hasenburg T, Langle F, Reibenwein B, et al. Current perioperative practice in rectal surgery in Austria and Germany. Int J Colorectal Dis 2010;25:855-63.

19. Petrowsky H, Demartines N, Rousson V, et al. Evidence-based value of probylactic drainage in gastrointestinal surgery. Ann Surg 2004;240:1074-84.




Randomized controlled trial to investigate the effect of metal clips on early migration during stent implantation for malignant esophageal stricture

Background: The rate of stent migration, especially in the short term after implantation, is high in the treatment process. We sought to explore an effective method for preventing early migration after stent implantation for malignant esophageal stricture and to provide the basis for clinical treatment.

Methods: We conducted a prospective, open-label, parallel-assignment random-ized controlled trial with patients undergoing stent implantation for malignant esophageal stricture. The proximal segments of stents in the treatment group were �xed with 2 metal clips during the perioperative period of esophageal stent implantation, while no treatment was used in the control group. All patients underwent radiography at 3 and 7 days and 1 and 3 months after placement to assess the stent migration.

Results: There were 83 patients in our study. Demographic characteristics were sim-ilar between the groups. There was no stent migration observed in the treatment group within 2 weeks of the operation, while stent migration was observed in 6 of 41 (14.6%) cases in the control group, occurring at 3 and 7 days after placement. There were no perioperative complications.

Conclusion: Perioperative �xation of the proximal segments of stents with metal clips is effective in preventing early stent migration.

Contexte : Le taux de migration des endoprothèses est élevé, surtout peu de temps après leur pose, au cours du processus thérapeutique. Nous avons voulu trouver une méthode ef�cace pour prévenir la migration précoce des endoprothèses peu après leur pose pour la sténose œsophagienne d’origine maligne et établir la base du traite-ment clinique.

Méthodes : Nous avons réalisé un essai prospectif ouvert randomisé et contrôlé selon une affectation parallèle auprès de patients soumis à la pose d’une endopro-thèse pour une sténose œsophagienne d’origine maligne. Les segments proximaux des endoprothèses dans le groupe traité ont été �xés à l’aide de 2 agrafes métalliques durant la période périopératoire de la pose de l’endoprothèse œsophagienne alors qu’aucun traitement n’a été utilisé dans le groupe témoin. Tous les patients ont subi une radiographie 3 et 7 jours, puis 1 et 3 mois après la pose de l’endoprothèse pour évaluer sa migration, le cas échéant.

Résultats : Notre étude comportait 83 patients. Les caractéristiques démo-graphiques étaient similaires entre les groupes. On n’a noté aucune migration de l’endoprothèse dans le groupe traité au cours des 2 semaines suivant l’intervention, tandis que la migration de l’endoprothèse a été observée chez 6 participants sur 41 (14,6 %) du groupe témoin, 3 et 7 jours après la pose. On n’a noté aucune complica-tion périopératoire.

Conclusion : La �xation périopératoire des segments proximaux des endoprothèses au moyen d’agrafes métalliques permet de prévenir ef�cacement la migration pré-coce des endoprothèses.

Changxiong Wang, MD Cui Lou, MD

Accepted for publication May 12, 2015

Correspondence to: C. Wang or C. Lui Digestive Endoscopy Center Lishui People’s Hospital Lishui 323000 Zhejiang, China [email protected] [email protected]

DOI: 10.1503/cjs.002615

random-wang.indd 378 2015-11-10 9:30 AM

RESEARCH


E sophageal cancer is one of the most common malig-nant tumours in China, ranking second in all diges-tive malignancies. China ranks �rst worldwide in

incidence of and death from esophageal cancer.1 When esophageal cancers are associated with progressive dyspha-gia, 60%–70% of them have already lost surgical indica-tions,2 and stent implantation remains the primary option.3–7 Esophageal stent implantation can rapidly re-establish the esophageal passage, relieve stricture symp-toms, improve the nutritional status and replace esopha-geal reconstruction surgery, which is risky and traumatic. Therefore, esophageal stent implantation is of high clinical importance.8 Because of various reasons, stent migration often occurs after implantation, especially in the short term. Between January 2011 and December 2013, we used metal clips to clamp and �x the esophageal stents during the perioperative period to prevent stent migration.

METHODS

We studied adult patients who underwent stent implanta-tion for malignant esophageal stricture in our hospital between January 2011 and December 2013. Diagnoses of all patients were con�rmed with gastroscopic and histo-logical examinations. The Clinical Trials Committee of Lishui People’s Hospital approved our study protocol, and all participants provided written informed consent before enrolling in the trial.

The patients were randomly assigned to the treatment or control groups using a random number table. We used an allocation concealment method in which the research-ers responsible for study grouping did not participate in the inclusion of participants or any other process during the trial. Our study was an open-label clinical trial because the assessors of stent migration could not be blinded. Each assessor’s results were con�rmed by a second person in order to reduce bias.

The equipment and materials used in this study were as follows: oral electronic gastroscope (Olympus GIF-H260), nasal gastroscope (Olympus GIF-N260), esophageal dilation bougie in diameter sizes of 5, 7 and 9 mm (Cook, SGD-100–1), Blue Zebra guidewire (Medi-Globe, GGW-03–35–450), silicone-coated esophageal stents with a diameter size of 20 mm and lengths of 80–120 mm (Micro-Tech Co. Ltd., MTN-SE), disposable esophageal stent inserter with a diam-eter of 8 mm and length of 650 mm (Micro-Tech Co. Ltd., MTN-SR) and cold saline. Uncovered metal stents were used in this study. Stent migration is de�ned as a deviation or change in the stent position in the human digestive tract, which leads to partial or complete loss of luminal dilation.

Electrocardiograms, blood tests and blood clotting time were examined in all patients, and the results matched the surgical requirements. Water deprivation and fasting were prescribed for 12 hours before the surgery, and lidocaine jelly was administered orally 10 min before the operation.

In the control group, an endoscope was inserted at the proximal end of the lesion site, and a Zebra guidewire was extended to the gastric cavity under radiography guidance. After the stricture site and length were con�rmed dually by endoscopy and radiography, a bougie was used to dilate the strictured segment to 9 mm. The inserters were placed at the corresponding sites along the guidewire. Sequentially, the stent was slowly released until complete apposition. Finally, the stent status was re-examined with gastroscopy. In the treatment group, the esophageal lumen was divided into 4 quadrants (anterior, posterior, left and right) under the endoscope, and 2 metal clips were symmetrically placed at the proximal end of the stent for �xation (Fig. 1 and Fig. 2). Stent position was observed on radiographs obtained 3 and 7 days and 1 and 3 months after placement.

Fig. 1. Use of 2 metal clips to �x the upper segment of the stent to prevent stent migration.

Fig. 2. Radiograph showing 2 metal clips �xed to the upper seg-ment of the stent.


RECHERCHE


Statistical analysis

We used Student t tests and χ2 tests to compare the baseline characteristics between the 2 groups. The χ2 test was used to compare the stent migration rates between the groups. We performed our statistical analysis using SPSS software version 18.0, and we considered results to be signi�cant at p < 0.05.

RESULTS

We included 83 patients in our study: 61 had squamous cell carcinoma, 21 had adenocarcinoma, and 1 had adenosqua-mous carcinoma. All patients had stage III or IV disease. The obstruction sites in 21 patients were in the mid-upper seg-ments; in the other 62 patients, they were in the lower seg-ments. Twenty-eight patients received radiotherapy, and the remaining patients either did not have surgical opportunities or refused surgery. Five patients could not drink (level 0 of dysphagia), 59 could eat only liquid food (level I), and 19 could have semiliquid food (level II). Patients were random-ized into 2 groups in parity using their hospital numbers, with 42 in the treatment group and 41 in the control group. No significant differences were found between the groups in demographic and clinical characteristics, such as sex, age, pathological type, clinical stage, obstruction site, lesion length and radiotherapy history (Table 1). In this study, all implanta-tions were primarily successful. Radiograph examinations

were performed 3 and 7 days and 1 and 3 months postopera-tively to observe the status of the stents. No dropout or loss to follow-up occurred. A �ow chart of enrolled patients is shown in Figure 3. The results indicated that the stents in all the patients were located appropriately with a dilation degree lon-ger than 1.5 cm. With a total effective rate of 100%, signi�-cant improvements could be observed in the dysphagia symp-toms of the patients from the treatment group 1 week postoperatively, and they could eat semiliquid food or soft food. Although no stent migrations were found 1 and 3 months postoperatively in the control group, 2 occurred 3 days postoperatively and 4 occurred 7 days postoperatively, resulting in a total effectiveness of 85.4% (Table 2). There were no perioperative complications.

DISCUSSION

As a palliative treatment, esophageal stent implantation is effective in resolving diseases, such as benign and malignant esophageal strictures and esophageal �stula, and has been widely applied in clinical practice. As more cancer patients survive, complications with stents are more frequently observed. The common complications include retrosternal pain, bleeding, re�ux, stent migration and loss, and resteno-sis.9 Stent migration is the most common complication clinically, with an incidence of 12.27%, accounting for 57.82% of all stent complications.10 The possible reasons include severe vomiting and improper diet, severe coughing and high tension, and overdilated esophageal lumen.11 Therefore, treatment for stent migration after esophageal stent implantation is a major problem for doctors.12 We share our successful experience in treating short-term stent migration after esophageal stent implantation, hoping to provide a basis for clinical treatment.

Long and colleages13 reported that the uncoated seg-ment of the esophageal stent would stimulate intralumen-oriented growth of the granulation tissues and that it would be extremely dif�cult to withdraw the stents 3 weeks later. In our study, the stent migration rate of the control group was 14.6%, and most of them occurred after 3–7 days. No stent migration was observed in the treatment group within 2 weeks of the operation; therefore, the difference between

Table 1. Demographic and clinical characteristics of study participants (n = 83)

Group; no.*†

Characteristic Treatment, n = 42 Control, n = 41

Sex

Male 29 27

Female 13 14

Mean age, yr 67.6 69.8

Pathological type

Squamous cell carcinoma 30 31

Adenocarcinoma 11 10

Adenosquamous carcinoma 1 0

Dysphagia degree

Level 0 2 3

Level 1 30 29

Level II 10 9

Obstruction site

Mid-upper segment 11 10

Lower segment 31 31

Lesion length, cm

4 10 10

6 21 22

8 11 9

Radiotherapy history

Yes 13 15

No 29 26

*Unless otherwise indicated. †All p > 0.05.

Table 2. Stent migration rates in the treatment and control groups (n = 83)

Group; no.*†

Migration Treatment, n = 42 Control, n = 41

Timing

3 d 0 2

7 d 0 4

1 mo 0 0

3 mo 0 0

Rate 0% 14.6%

*Unless otherwise indicated. †χ2 = 4.62, p = 0.032.


RESEARCH


these 2 groups was signi�cant (p = 0.032). No stent migra-tion occurred in either group at 1 month or 3 months, which indicated that the stent was �xed to the esophageal lumen 2–3 weeks postoperatively and that migration was unlikely to happen; therefore, preventive treatment should be performed during the perioperative period. After the endoscopic removal of the metal clips, granulation tissues, which are similar to those induced by surgical sutures, could be observed. These granulation tissues would detach from the stent spontaneously and would then be excreted through the digestive tract 1–4 weeks later, usually without complication.14 We think application of metal clips within 2 weeks of the operation will prevent stent migration. Two weeks later, when the stent is fully released, the metal clips will detach from the stent spontaneously.

Limitations

Measures to reduce bias in our study were the random-ized control method, enrolment of inpatients, good

patient compliance, trained researchers and appropriate statistical analysis. However, the sample size was small owing to insuf�cient funds and the time and number of researchers, but we will increase the sample size in future studies. We believe our approach was appropriate and rational.

CONCLUSION

Perioperative �xation of the proximal segments of stents with metal clips is effective in preventing stent migration. How-ever, there are still 2 noteworthy points. First, 2 metal clips should be used in the operation because 1 clip is de�nitely not effective enough and more than 2 clips will increase the eco-nomic burden of the patient. Second, the prestenting esopha-geal lumen expansion should not exceed 9 mm, and the stric-ture length can be determined once the nasal gastroscope penetrates the stricture. If the esophageal lumen is overdil-ated, the stent is prone to migration or even loss; as the insert-er’s diameter is only 8 mm, the 9 mm dilation is wide enough.

Fig. 3. Flow of patients through the clinical trial.

83 esophageal carcinoma strictures

No signi�cant difference in baseline

Routine endoscopic stent placement +2 titanium clips for �xation, stent

position recorded

42 cases in the treatment group

Randomization

41 cases in the control group

Routine endoscopic stent placement, stent position recorded

Radiograph examination, stent position recorded at:

3 days 7 days

1 month 3 months

3 days 7 days

1 month 3 months

Stent migration found in 2 cases at day 3 and 4 cases at day 7 during

follow-up

No stent migration found duringfollow-up

Data collection and analysis of stent migration in the 2 groups

Radiograph examination, stent position recorded at:


RECHERCHE


Acknowledgments: The authors thank their colleagues from the Digestive Endoscopy Center, Lishui People’s Hospital, for their com-ments and support.

Af�liations: From the Digestive Endoscopy Center, Lishui People’s Hospital, Lishui, Zhejiang, China (Wang); the Sixth Af�liated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (Wang); and the Department of Gastroenterology, Jinyun County Hospital of traditional Chinese Medicine, Zhejiang, China (Lou).


Contributors: Both authors designed the study and acquired the data, which C. Wang analyzed. Both authors wrote and reviewed the article and approved the �nal version for publication.

References

1. National Cancer Research Of�ce, Statistical Information Center of Ministry of Health. Research report on risk factor of cancer in China. 2003, Beijing: China Union Medical University Press.

2. Homs MY, Steyerberg EW, Eijkenboom WM, et al. Single-dose brachytherapy versus metal stent placement for the palliation of dyspha-gia from oesophageal cancer: multicentre randomised trial. Lancet 2004;364:1497-504.

3. Lazaraki G, Katsinelos P, Nakos A, et al. Malignant esophageal dyspha-gia palliation using insertion of a covered Ultra�ex stent without �uor-oscopy: a prospective observational study. Surg Endosc 2011;25:628-35.

4. Ge X. Clinical application of covered stents in treating esophageal malignant stenosis [article in Chinese]. J Clin Rehabil Tissue Eng Res 2010;14:702-5.

5. Conio M, Blanchi S, Filiberti R, et al. Self-expanding plastic stent to palliate symptomatic tissue in/overgrowth after self-expanding metal stent placement for esophageal cancer. Dis Esophagus 2010;23:590-6.

6. Dumitra A, Sabau A, Maniu D, et al. Particular aspects of endopros-thesis in malignant advanced pharingeal-esophageal stenosis. Chirurgia (Bucur) 2011;106:327-32.

7. Vleggaar FP, Siersema PD. Expandable stents for malignant esopha-geal disease. [vii.]. Gastrointest Endosc Clin N Am 2011;21:377-88.

8. Burstow M, Kelly T, Panchani S, et al. Outcome of palliative esopha-geal stenting for malignant dysphagia: a retrospective analysis. Dis Esophagus 2009;22:519-25.

9. Huang ZW, Zhang QK, Wen MZ, et al. Analysis of the complications of malignant esophagus stenosis from stenting [article in Chinese]. J Chin Clin Med Imaging 2007;18:305-7.

10. Feng ZQ, Nie YQ. Literature analysis of endoscopic treatment of benign esophageal perforations with covered metal stents [article in Chinese]. Chin J Endosc 2012;18:147-50.

11. Gao G, Cao JB, Li SJ, et al. Prevention of stent migration and loss in esophageal stenting for patients with achalasia [article in Chinese]. Hebei Med J 2009;31:2767-8.

12. Yin SW, Xiang YM, Ye LA. The complication and management of esophageal stent in the treatment of esophageal strictures and �stula [article in Chinese]. Mod Med Imageology 2007;16:204-6.

13. Long HD, Yin SW, Wu X, et al. Pick-up and replacement shift esophageal stent [article in Chinese]. Anhui Med J 2011;32:511-3.

14. Xu GM, Li ZS. Upper gastrointestinal endoscopy. 1st ed. 2003, Shang-hai: Shanghai Science and Technology Press.

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Effects of adding Braun jejunojejunostomy to standard Whipple procedure on reduction of afferent loop syndrome — a randomized clinical trial

Background: Whipple surgery (pancreaticodeudenectomy) has a high complication rate. We aimed to evaluate whether adding Braun jejunojejunostomy (side-to-side anastomosis of afferent and efferent loops distal to the gastrojejunostomy site) to a standard Whipple procedure would reduce postoperative complications.

Methods: We conducted a randomized clinical trial comparing patients who underwent standard Whipple surgery (standard group) and patients who underwent standard Whipple surgery with Braun jejunojejunostomy (Braun group). Patients were followed for 1 month after the procedure and postoperative complications were recorded.

Results: Our study included 30 patients: 15 in the Braun and 15 in the standard group. In the Braun group, 4 (26.7%) patients experienced 6 complications, whereas in the stan-dard group, 7 (46.7%) patients experienced 11 complications (p = 0.14). Complications in the Braun group were gastrointestinal bleeding and wound infection (n = 1 each) and delayed gastric emptying and pulmonary infection (n = 2 each). Complications in the standard group were death, pancreatic anastomosis leak and biliary anastomosis leak (n = 1 each); gastrointestinal bleeding (n = 2); and afferent loop syndrome and delayed gastric emptying (n = 3 each). There was no signi�cant difference between groups in the sub-types of complications.

Conclusion: Our results showed that adding Braun jejunojejunostomy to standard Whipple procedure was associated with lower rates of afferent loop syndrome and delayed gastric emptying. However, more studies are needed to de�ne the role of Braun jejunojejunostomy in this regard.

Trial registration: IRCT2014020316473N1 (www.irct.ir)

Contexte : La chirurgie de Whipple (pancréatoduodénectomie) s’accompagne de taux de complications élevés. Nous avons voulu véri�er si l’ajout d’une jéjunojéjunostomie de Braun (anastomose latérolatérale des anses afférente et efférente à la partie distale de la gastrojéjunostomie) à une chirurgie de Whipple standard permet de réduire les com-plications postopératoires.

Méthodes : Nous avons procédé à un essai clinique randomisé pour comparer des patients soumis à une chirurgie de Whipple standard (groupe standard) à des patients soumis à une chirugie de Whipple standard avec jéjunojéjunostomie de Braun (groupe Braun). Les patients ont été suivis pendant 1 mois après l’intervention et les complica-tions postopératoires ont été notées.

Résultats : Notre étude a regroupé 30 patients : 15 dans le groupe Braun et 15 dans le groupe standard. Dans le groupe Braun, 4 patients (26,7 %) ont présenté 6 complications, tandis que dans le groupe standard, 7 patients (46,7 %) ont présenté 11 complications (p = 0,14). Les complications dans le groupe Braun ont été saignements gastro -intestinaux et infection de plaie (n = 1 chacun) et retard de la vidange gastrique et infection pulmonaire (n = 2 chacun). Les complications dans le groupe standard ont été décès, fuite de l’anastomose pancréatique et fuite de l’anastomose biliaire (n = 1 chacun); saignement gastro-intestinal (n = 2); et syndrome de l’anse afférente et retard de la vidange gastrique (n = 3 chacun). On n’a noté aucune différence signi�cative entre les groupes pour ce qui est des sous-types de complications.

Conclusion : Nos résultats ont montré que l’ajout de la jéjunojéjunostomie de Braun à une chirurgie de Whipple standard a été associé à des taux moindres de syndrome de l’anse afférente et de retard de la vidange gastrique. Il faudra toutefois procéder à d’autres études pour dé�nir le rôle de la jéjunojéjunostomie de Braun à cet égard.

Enregistrement de l’essai: IRCT2014020316473N1 (www.irct.ir)

Farzad Kakaei, MD Samad Beheshtirouy, MD Seyed Moahammad Reza Nejatollahi, MD Iqbal Rashidi, MD Touraj Asvadi, MD Afshin Habibzadeh, MD Mohammad Oliaei-Motlagh, MD


Correspondence to: F. Kakaei Department of Surgery Tabriz University of Medical Sciences Imam Reza Hospital Golgahst St. Tabriz, Iran [email protected]

DOI: 10.1503/cjs.005215

effects-kakaei.indd 383 2015-11-10 9:27 AM

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P ancreaticoduodenectomy, as �rst described by Allen Whipple in 1935, is a well-established operation and standard treatment for operable pancreatic head and

other periampullary tumours.1–3 Although this operation has a great impact on treatment and patient survival, up to 60% of patients experience various complications, including post-operative bleeding, delayed gastric emptying, afferent loop syndrome, and systemic complications, such as sepsis, deep vein thrombosis and infection.4

In order to reduce these complications, particularly delayed gastric emptying and afferent loop syndrome, vari-ous methods for anastomosis, including pyloric preserva-tion, Roux-en-Y, or different methods of intestinal loop resection to separate pancreatic anastomosis from other anastomoses, are introduced to use with or replace the stan-dard Whipple procedure. The Roux-en-Y method has been reported to reduce postoperative complications of Whipple surgery, especially pancreatic �stula and delayed gastric emptying.5 Braun jejunojejunostomy (side-to-side anasto-mosis of afferent and efferent loops distal to the gastrojeju-nostomy site) is functionally equal to Roux-en-Y, but is per-formed in less time and could replace Roux-en-Y in Whipple surgery. However, there are few reports demon-strating the ef�cacy of Braun jejunojejunostomy in reducing postoperative delayed gastric emptying or afferent loop syndrome.6 We aimed to evaluate the ef�cacy of adding Braun jejunojejunostomy to the standard Whipple surgery in reducing these type of postoperative complications.

METHODS

Study design and participants

Between June and December 2013, patients aged 18–75 years with con�rmed operable pancreatic head, duodenal or common bile duct tumours who were sched-uled for a Whipple procedure at Tabriz Imam Reza hos-pital, Tabriz University of Medical Sciences, were recruited for this study. Patients with previous upper abdominal surgery, preoperative signs of inoperability according to imaging studies (e.g., mesenteric or portal vein or superior mesenteric artery involvement, distant metastases, nearby organ involvement) or general condi-tions not suitable for a Whipple procedure (e.g., heart or renal failure) were excluded from the study. We also excluded patients whose tumours were found to be inop-erable according to intraoperative �ndings and patients who died during the operation.

The study was a prospective, randomized clinical trial designed by the surgery department and approved by the Institutional Review Board and Ethics Committee of Tabriz University of Medical Sciences. The trial was registered in the Iranian Registry of Clinical Trials (IRCT2014020316473N1; www.irct.ir). We obtained written informed consent from all patients.

Sample size

The trial was powered to detect an effect size of d ≥ 0.70 as statistically signi�cant in a 2-tailed test with α = 0.05 and a power of 0.90 with 14 participants per condition. As there was a possibility that some patients would not com-plete the study, we recruited 15 participants per group.

Randomization and blinding

Randomization of patients into 2 equal groups was per-formed using Randlist software (DatInf). The control group underwent the standard Whipple procedure (stan-dard group). In the intervention group (Braun group), a Braun jejunojejunostomy was added at the end of the stan-dard Whipple procedure. The attending surgeon received a sealed envelope in the operating room indicating the type of operation to be performed. The envelopes were unsealed only after complete resection of the pancreatico-duodenal complex. All the preoperative and postoperative clinical and paraclinical data were collected, and the follow-up was done by another member of the team who was completely blind to the type of surgery.

Pancreaticoduodenectomy procedure

All patients underwent the standard Whipple procedure, including 20%–40% distal gastrectomy, cholecystectomy, pancreaticoduodenectomy and then pancreaticojeju-nostomy, choledochojejunostomy and antecolic gastro-jejunostomy. All anastomoses were performed using the appropriate size of PDS II polydioxanone sutures (Ethicon, Johnson & Johnson). In the intervention group, Braun jejunojejunostomy was added to other anastomoses at the end of the operation. In both groups, pancreatico-jejunostomy was performed using the duct-to-mucosa method in 2 layers. Jejunojejunostomy was performed using a standard, manual 2-layer method (side-to-side anastomosis of afferent and efferent loops distal to the gastrojejunostomy site). The jejunojejunostomy site was performed between the proximal and distal jejunal loops about 30 cm distal to the choledochojejunostomy and 45 cm distal to the gastrojejunostomy sites, respectively. At the end of operation, 2 corrugated drains were inserted bilaterally in the liver and pancreas bed. Drainage �uid was collected by sterile colostomy-type bags every 6 hours until the removal of the drains.

Postoperative management

Postoperative treatment included prophylactic antibiotics (cefazolin and metronidazole), intravenous pantoprazole (as the prophylaxis against stress ulceration) for 1 week and 100 µg of subcutaneous octreotide 3 times per day for 48 hours. Antibiotics were continued for any infectious


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complications or changed according to the cultures of body �uids when needed. Patients spent at least 24 hours in the intensive care unit (ICU) and were transferred to the general ward when their hemodynamic and respira-tory conditions were stable. Nasogastric tubes were removed after 48 hours if the bowel sounds returned, and patients were started on a soft diet usually on the �fth postoperative day.

Patient characteristics and outcome measures

We collected the following data using a checklist to compare the 2 groups: age, sex, body mass index, time from the �rst symptoms until the operation, cause of the disease (pancreatic head, duodenal, or common bile duct tumour), duration of the operation, intraoperative bleeding and total volume of intraoperative blood prod-uct transfusion. We also collected the following labora-tory data: white blood cell count, hemoglobin level, ala-nine aminotransferase, aspartate aminotransferase, and total and direct bilirubin both preoperatively and post-operatively on days 1, 3, 5, 7 and 14. We recorded the volume of nasogastric tube evacuations for 48 hours after the operation as well as the number of times per day that patients vomited after the nasogastric tubes were extracted. We noted postoperative complications, including death and its cause, pancreatic anastomosis leakage, gastric anastomosis leakage, biliary anastomosis leakage, postoperative bleeding requiring another oper-ation, postoperative gastrointestinal bleeding requiring another operation, afferent loop syndrome, delayed gas-tric emptying, surgical site infection, pulmonary infec-tion and deep vein thrombosis. Patients were followed for 1 month after the operation or until in-hospital death.

Primary outcome measures were afferent loop syn-drome, defined as sudden, bulky bile-stained vomit un related to eating; volume of nasogastric tube evacua-tions in the 48 hours after the operation; frequency of vomiting after extraction of nasogastric tubes; and delayed gastric emptying, de�ned as gastric stasis requiring naso-gastric intubation for 10 days or more or the inability to tolerate a regular diet 14 days after the operation.

Secondary outcome measures were biliary leakage, de�ned as persistent secretion of bilirubin-rich drainage �uid of more 50 mL/d from drains; postoperative intra-abdominal bleeding, de�ned as the need for more than 2 units of red blood cells more than 24 hours after sur-gery or repeat laparotomy because of bloody discharge from the drains; and gastrointestinal bleeding, de�ned as the need for more than 2 units of red blood cells more than 24 hours after surgery or need for any surgical or endoscopic intervention because of bloody discharge from the nasogastric tube or lower gastrointestinal bleed-ing (melena or hematochezia).


All data were analyzed using the Statistical Package for Social Sciences, version 17.0 (SPSS). Baseline data are reported as means ± standard deviations for continuous data or as per-centages for categorical data. In order to analyze the differ-ences between the groups in the quantitative variables, we used the Student t test for normally distributed data and the Mann–Whitney U test for non-normally distributed data. We studied the association between qualitative variables using the χ2 test or Fisher exact test. We considered results to be signi�cant at p < 0.05.

RESULTS

We included 30 patients in our analysis: 15 who underwent a standard Whipple procedure alone and 15 who under-went a standard Whipple procedure combined with Braun jejunojejunostomy. No patients were lost to follow-up (Fig. 1). There were no signi�cant differences in baseline demographic and clinical characteristics between the groups (Table 1). The most common cause for surgery in both groups was pancreatic head tumour (n = 19), followed by obstructive jaundice with probable periampullary tumour (n = 5), duodenal tumour (n = 3), bile duct cancer (n = 2) and other disease (n = 1).

Perioperative �ndings

Mean duration of surgery was 6.23 ± 1.83 hours in the Braun group compared with 6.08 ± 1.55 hours in the stan-dard group (p = 0.81). Mean bleeding volume during sur-gery was 500.00 ± 142.00 mL in the Braun group and 626.66 ± 145.23 mL in the standard group (p = 0.53). There was no signi�cant difference between the Braun and stan-dard groups in mean packed red blood cells (1.60 ± 1.35 v. 1.33 ± 1.17 units, p = 0.56) or fresh frozen plasma (0.40 ± 0.28 v. 1.06 ± 0.54 units, p = 0.29) used during surgery.

Postoperative �ndings

Mean nasogastric tube drainage was 468.00 ± 414.88 mL in the Braun group and 760.71 ± 503.51 mL in the standard group (p = 0.09). The standard group had signi�cantly more periods of vomiting after nasogastric tube removal than the Braun group (1.54 ± 1.50 v. 0.53 ± 0.51 times/d, p = 0.032). We observed 6 complications in 4 (26.70%) patients in the Braun group compared with 11 complications in 7 (46.7%) patients in the standard group. Although the rate of compli-cations in the Braun group was lower than in the standard group, the difference was not signi�cant (p = 0.14). There was no signi�cant difference between groups in the subtypes of postoperative complications (Table 1). There was 1 death in the standard group, which occurred due to pulmonary embolism. One patient in the Braun group had pancreatitis,


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which was managed conservatively, and 1 patient experi-enced biliary leak, which was managed conservatively. Three patients in the standard group had recurrent nausea and vomiting as well as afferent loop syndrome and underwent

Braun jejunojejunostomy. One case of afferent loop syn-drome occurred with postoperative bleeding. All cases of postoperative bleeding occurred at the gastrojejunostomy site and were controlled and managed conservatively. Table 2 summarizes the complications in our patients.

DISCUSSION

Braun jejunojejunostomy has been recommended as an adjacent method to a standard Whipple procedure to reduce postoperative delayed gastric emptying and afferent loop syndrome, and it is shorter than other methods such as Roux-en-Y diversion.7–9 Vogel and colleagues7 reported that postoperative complications, including enterogastric re�ux and biliary re�ux, were signi�cantly less frequent in patients undergoing Braun jejunojejunostomy than in those undergoing any types of gastrojejunostomy without adding Braun jejunojejunostomy. Another study reported that adding Braun jejunojejunostomy after gastroenteros-tomy in patients with biliary re�ux signi�cantly reduced the reflux.8 Wang and colleagues9 documented a lower complication rate after adding Braun anastomosis to a standard Whipple procedure. In the present clinical trial, we evaluated the postoperative complications after stan-dard Whipple surgery with or without Braun jejunojeju-nostomy. There was no significant difference between groups before or during the operation. Six complications were seen in 4 patients in the Braun group, and 11 compli-cations were seen in 7 patients in the standard group, but the difference was not signi�cant. We also observed no dif-ference between groups in nasogastric tube volume; how-ever, vomiting after the tube removal occurred signifi-cantly more frequently in the standard group. Hochwald

Table 1. Baseline demographic and clinical characteristics of participants

Group; no. (%) or mean ± SD

Characteristic Braun Standard p value

Age 57.26 ± 13.80 55.26 ± 13.15 0.82

Sex

Male 10 (66.7%) 10 (66.7%) —

Female 5 (33.3%) 5 (33.3%) —

Body mass index

< 20 5 (33.3%) 3 (20%) —

20–25 8 (53.3%) 10 (66.7%) —

26–30 1 (6.7%) 1 (6.7%) —

> 30 1 (6.7%) 1 (6.7%) —

Symptom duration, d 159.33 ± 34.34 173.20 ± 52.28 0.68

Reason for surgery

Pancreatic head tumour 8 (53.3%) 11 (73.3%) —

Duodenum tumour 3 (20%) 0 —

Tumour of distal coledoc 1 (6.7%) 1 (6.7%) —

Obstructive jaundice with possible tumour of ampul water

2 (13.3%) 3 (20%) —

Others 1 (6.7%) 0 —

SD = standard deviation.

Fig. 1: Flow of patients through the trial.

Assessed for eligibility (n = 60)

Excluded (n = 30): Not meeting criteria (n = 25) Refused to participate (n = 5)

Randomization (n = 30)

Braun group (n =15)

Standard group (n =15)

Lost to follow-up (n = 0)

Lost to follow-up (n = 0)

Analyzed (n =15) Excluded from analysis

(n = 0)

Analyzed (n =15) Excluded from analysis

(n = 0)


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and colleagues10 documented earlier nasogastric tube removal in patients undergoing Braun anastomosis than in those undergoing a standard Whipple procedure; however, they reported no signi�cant difference in vomiting rate or reinsertion of the nasogastric tube between groups.

Various complications have been reported following standard Whipple surgery. In one study, anastomosis leak, delayed gastric emptying and bleeding were the prevalent complications of Whipple surgery.11 In another study, post-operative bleeding was the most common complication after surgery.12 In yet another study,13 fever, pancreatic �s-tula and increase in bilirubin levels were the prevalent com-plications.13 In our study, complications in the standard group were death, pancreatic and biliary anastomosis leak-age, gastrointestinal bleeding, afferent loop syndrome and delayed gastric emptying. Complications in the Braun group were gastrointestinal bleeding, wound infection, delayed gastric emptying and pulmonary infection. There was no signi�cant difference between the groups in the rate of complications observed. We observed pancreatic anasto-mosis and biliary anastomosis leak only in the standard group, whereas Hochwald and colleagues10 reported similar failure of pancreatic anastomosis between the groups.

In our study, delayed gastric emptying was observed in 13.3% cases in the Braun group and 20% of cases of the standard group. Similarly, Hochwald and colleagues10 and Nikfarjam and colleagues14 observed that delayed gastric emptying was signi�cantly reduced after Braun anastomosis. Conversely, Jurgens and colleagues8 reported a gastric emp-tying complication rate of 81% after Braun anastomosis. However, 57% of these patients had gastroparesis before the operation; 42% of of those with delayed gastric emptying responded to medical therapy and the symptom improved.

Afferent loop syndrome is an unusual complication with a reported incidence of 0.2%–20%. It usually occurs after gastrojejunostomy with Billroth II reconstruction and par-tial gastrectomy. However, this complication could occur even after surgical resection and anastomosis between gas-

tric and other parts of the foregut, such as in a pancreatico-duodenectomy procedure.15,16 In our study study, afferent loop syndrome was observed in 3 (20%) patients in the standard group, whereas no patients in the Braun group experienced this complication. Considering our �ndings, it is possible that Braun jejunojejunostomy was associated with the decrease in this complication rate.

Braun anastomosis has some potential advantages. It tends to stabilize the afferent and efferent limbs of the gas-trojejunostomy, so the gastrojejunostomy has a low ten-dency to twist and angulate. Braun anastomosis prevents any increase in pressure in the biliopancreatic limb if an obstruc-tion occurs at the level of the gastroenterostomy. The Braun anastomosis also allows gastric content to pass distally unim-peded into either the efferent or afferent limb of the gastro-enterostomy. Kinking at either of these limbs alone theoret-ically would not alter gastric emptying in these circumstances.14,17 These advantages could prevent the occurrence of afferent loop syndrome.

Limitations

Although the occurrence of afferent loop syndrome did not differ significantly between the standard group and the Braun jejunojejunostomy group, the difference was clinically important, Braun jejunojejunostomy was associated with a reduced rate of complications. However, observing signi�-cant �ndings in previous studies and no signi�cant differ-ences in our study could be related to the smaller number of patients included in our study. Overall �ndings indicate the ef�cacy of adding Braun jejunojejunostomy to a standard Whipple procedure to reduce postoperative complications, especially the incidence of afferent loop syndrome and delayed gastric emptying.

CONCLUSION

Adding Braun jejunojejunostomy to a standard Whipple procedure may be associated with lower rates of afferent loop syndrome and delayed gastric emptying. More studies are necessary to de�ne the role of Braun jejunojejunostomy in this regard.

Acknowledgments: This research was �nancially supported by the Vice Chancellor for Research, Tabriz University of Medical Sciences, Iran.

Af�liations: From the Department of Surgery, Tabriz University of med-ical sciences, Imam Reza Hospital, Tabriz, Iran (Kakaei, Beheshtirouy, Rashidi, Asvadi, Habibzadeh, Oliaei-Motlagh); and the Department of Surgery, Shahid Beheshti University of Medical Sciences, Ayatollah Taleghani Hospital, Evin, Tehran, Iran (Nejatollahi).


Contributors: F. Kakaei, S. Beheshtirouy, S.M.R. Nejatollahi and A. Habibzadeh designed the study. F. Kakaei, I. Rashidi, T. Asvadi and A. Habibzadeh acquired the data, which I. Rashidi, A. Habibzadeh and M. Oliaei-Motlagh analyzed. F. Kakaei, I. Rashidi, T. Asvadi and A. Habibzadeh wrote the article, which all authors reviewed and approved for publication.

Table 2. Postoperative complications between groups

Group; no. (%)

Complication Braun Standard p value

Death after operation 0 1 (6.7%) 0.90

Anastomosis leak

Pancreas 0 1 (6.7%) 0.90

Gastric 0 0 —

Biliary 0 1 (6.7%) 0.90

Postoperative bleeding 1 (6.7%) 2 (13.3%) 0.90

Postoperative bleeding requiring surgery

0 0 —

Afferent loop syndrome 0 3 (20%) 0.22

Delayed gastric emptying 2 (13.3%) 3 (20%) 0.90

Wound infection 1 (6.7%) 0 0.90

Pulmonary infection 2 (13.3%) 0 0.48

Deep vein thrombosis 0 0 —


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References 1. Distler M, Rückert F, Hunger M, et al. Evaluation of survival in

patients after pancreatic head resection for ductal adenocarcinoma. BMC Surg 2013;13:12.

2. Büchler MW, Wagner M, Schmied BM, et al. Changes in mortality after pancreatic resection: towards the end of completion pancreatectomy. Arch Surg 2003;138:1310-4.

3. Balcom JH, Rattner DW, Warshaw AL, et al. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001;136:391-8.

4. Sohn TA, Campbell KA, Pitt HA, et al. Quality of life and long-term survival after surgery for chronic pancreatitis. J Gastrointest Surg 2000;4:355-65.

5. Shimoda M, Kubota K, Katoh M, et al. Effect of Billroth II or Roux-en-Y reconstruction for the gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled study. Ann Surg 2013;257:938-42.

6. Qu H, Sun GR, Zhou SQ, et al. Clinical risk factors of delayed gastric emptying in patients after pancreaticoduodenectomy: a systematic review and meta-analysis. Eur J Surg Oncol 2013;39:213-23.

7. Vogel SB, Drane WE, Woodward ER. Clinical and radionuclide evaluation of bile diversion by Braun enteroenterostomy: prevention and treatment of alkaline re� ux gastritis. An alternative to Roux-en-Y diversion. Ann Surg 1994;219:458-65, discussion 465-6.

8. Jurgens MJ, Drane WE, Vogel SB. Dual-radionuclide simultaneous biliary and gastric scintigraphy to depict surgical treatment of bile re� ux. Radiology 2003;229:283-7.

9. Wang L, Su AP, Zhang Y, et al. Reduction of alkaline re� ux gastritis and marginal ulcer by modi� ed Braun enteroenterostomy in gastroen-terologic reconstruction after pancreaticoduodenectomy. J Surg Res 2014;189:41-7.

10. Hochwald SN, Grobmyer SR, Hemming AW, et al. Braun enteroen-terostomy is associated with reduced delayed gastric emptying and early resumption of oral feeding following pancreaticoduodenectomy. J Surg Oncol 2010;101:351-5.

11. Choon KH, Kleeff J, Friess H, et al. Complications of pancreatic surgery. HPB 2005;7:99-108.

12. Puppala S, Patel J, McPherson S, et al. Hemorrhagic complications after Whipple surgery: imaging and radiologic intervention. AJR Am J Roentgenol 2011;196:192-7.

13. Gervais DA, Fernandez-del Castillo C, O’Neill MJ, et al. Complications after pancreatoduodenectomy: imaging and imaging-guided interven-tional procedures. Radiographics 2001;21:673-90.

14. Nikfarjam M, Houli N, Tufail F, et al. Reduction in delayed gastric emptying following non-pylorus preserving pancreaticoduodenec-tomy by addition of a Braun enteroenterostomy. JOP 2012;13:488-96.

15. Aimoto T, Uchida E, Nakamura Y, et al. Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases. J Nippon Med Sch 2006;73:226-30.

16. Wood� eld CA, Levine MS. The postoperative stomach. Eur J Radiol 2005;53:341-52.

17. Tu BN, Sarr MG, Kelly KA. Early clinical results with the uncut Roux reconstruction after gastrectomy: limitations of the stapling technique. Am J Surg 1995;170:262-4.

CALL FOR ADDITIONAL ASSOCIATE EDITORS, CANADIAN JOURNAL OF SURGERY

The editors-in-chief welcome applications to join the CJS editorial board as associate editors. Manuscript submissions to CJS are assigned to associate editors according to their special interest sections (see list www.canjsurg.ca/about). The workload is tailored to the associate editor’s availability. Support for the associate editor from the editors-in-chief, the editorial staff and the computerized manuscript management program facilitate the work so that it is rewarding and not onerous. Associate editors may write commentaries and manage special interest sections on the website (see www.canjsurg.ca /collections/). The goal of the editorial board is to promote excellence in Canadian surgery and surgical research reporting — your support is essential.

Applications may be sent to Edward Harvey and Vivian McAlister at [email protected]. Submissions should include an abbreviated resumé and a designation of preferred section(s) of interests (see www.canjsurg.ca/about).

CALL FOR ADDITIONAL ASSOCIATE EDITORS, CANADIAN JOURNAL OF SURGERY

The editors-in-chief welcome applications to join the associate editors. Manuscript submissions to according to their special interest sections (see list www.canjsurg.ca/about). The workload is tailored to the associate editor’s availability. Support for the associate editor from the editors-in-chief, the editorial staff and the computerized manuscript management program facilitate the work so that it is rewarding and not onerous. Associate editors may write commentaries and manage special interest sections on the website (see www.canjsurg.ca




Early clinical experience with the POEM procedure for achalasia

Background: Per oral endoscopic myotomy (POEM) is a viable alternative to stan-dard Heller myotomy for surgical treatment of achalasia. Outcomes from the United States, Europe and Asia have been reported. We sought to report data after the initiation of POEM in a Canadian centre.

Methods: We enrolled patients with achalasia in a research ethics board–approved pilot study. Surgeons learned the POEM procedure in a systematic manner that included visiting experts in POEM, practice in an animal laboratory and mentoring from POEM experts. Preoperative evaluation included manometry, 24-hour pH, barium swallow, endoscopy and Eckhardt Symptom Score. All patients underwent gastrograf�n swallow on postoperative day 1. Patients were re-evaluated using the Eckhardt score on postoperative day 14.

Results: Ten patients underwent POEM. Seven patients had previous endoscopic treatments: 6 had balloon dilataion and 1 had botulinum toxin injection. Mean pre-operative Eckhardt score was 8.1 ± 2.4. Mean preoperative lower esophageal sphinc-ter resting and residual pressure was 32.3 ± 9.2 and 20.8 ± 5.3, respectively. Mean duration of surgery was 141.3 ± 43.7 minutes. Mean length of hospital stay was 1 day. No major perioperative complications occurred. On postoperative day 14, the mean Eckhardt score was 1 ± 1.2.

Conclusion: Our approach to POEM introduction was systematic and deliberate. The procedure is safe, feasible and has good perioperative outcomes. Our early results are consistent with current literature.

Contexte : La myotomie perorale endoscopique (POEM) est une solution de rechange viable à la myotomie de Heller standard pour le traitement chirurgical de l’achalasie. Des rapports ont fait état de résultats enregistrés aux États-Unis, en Europe et en Asie. Nous avons voulu faire le point après l’instauration de la méthode POEM dans un centre canadien.

Méthodes : Nous avons inscrit des patients atteints d’achalasie à une étude de recherche pilote, approuvée par le comité d’éthique. Les chirurgiens se sont initiés à la technique POEM de façon systématique auprès d’experts de cette technique, en s’exerçant sur des animaux de laboratoire et ensuite auprès d’experts-mentors. L’examen préopératoire incluait : manométrie, pH des 24 heures, repas baryté, endoscopie et score d’Eckardt (pour les symptômes). Tous les patients ont subi un transit du grêle avec Gastrogra�n au jour 1 postopératoire. Le score d’Eckardt des patients a été réévalué au jour 14 postopératoire.

Résultats : Dix patients ont subi la technique POEM. Sept avaient déjà reçu des traitements endoscopiques : 6 avaient subi une dilatation par ballonnet et 1 avait reçu une injection de toxine botulique. Le score d’Eckardt préopératoire moyen était de 8,1 ± 2,4. La pression préopératoire moyenne du sphincter œsophagien inférieur au repos et résiduelle était de 32,3 ± 9,2 et de 20,8 ± 5,3, respectivement. La durée moyenne de la chirurgie a été de 141,3 ± 43,7 minutes. La durée moy-enne du séjour hospitalier a été d’un jour. Aucune complication périopératoire majeure n’est survenue. Au jour 14 postopératoire, le score d’Eckardt moyen était de 1 ± 1,2.

Conclusion : Notre approche à l’instauration de la technique POEM a été systé-matique et délibérée. L’intervention s’est révélée sécuritaire, réalisable et a procuré des résultats périopératoires positifs. Nos résultats préliminaires concordent avec ceux de la littérature actuelle.

Dennis Hong, MD, MSc Radu Pescarus, MD Rana Khan, MD Luciano Ambrosini, MD Mehran Anvari, MB, PhD Margherita Cadeddu, MD

This paper was presented at the Canadian Surgery Forum, Vancouver, BC, Sept. 17–21, 2014.


Correspondence to: D. Hong 50 Charlton Ave E Rm G814 St. Joseph’s Healthcare Hamilton ON L8N 4A6 [email protected]

DOI: 10.1503/cjs.017214

early-hong.indd 389 2015-11-10 9:48 AM

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A chalasia is a rare disease characteritzed by nonperi-staltic esophagus and incomplete relaxation of the lower esophageal sphincter (LES). These 2 charac-

teristics are the basis of the symptoms of achalasia that include dysphagia, regurgitation, reflux, vomiting and weight loss.

Treatments for achalasia include medical, endo-scopic and surgical therapy. Medications, such as cal-cium channel blockers and nitrates, are generally inef-fective and poorly tolerated.1 Endoscopic treatments include botulinum toxin injections and balloon dilata-tion. Endoscopic botox injections are usually recom-mended for elderly patients and poor operative candi-dates. Endoscopic balloon dilatation is an effective treatment for achalasia; however, it is associated with a relatively high perforation rate and may require repeated treatments.2 The main surgical therapy is a Heller myotomy with a partial fundoplication. Several studies have shown this to be an effective treatment for achalasia.3–6 The newest surgical treatment for achala-sia is per oral endoscopic myotomy (POEM), an endo-scopic treatment that divides the circular esophageal muscle fibres through a submucosal tunnel in the esophagus. The muscle �bre division includes the LES and at least 2 cm into the stomach. Small case series from various institutions have shown POEM to be safe and viable.7–10 To our knowledge, there have been no studies from a Canadian institution.

The objective of this study was to assess the safety, feasibility and observed perioperative outcomes of POEM as a treatment for achalasia in a Canadian institution.

METHODS

Our research ethics board (REB) approved a pilot study offering POEM for the treatment of achalasia to patients who met the inclusion criteria. Exclusion cri-ter ia were previous esophageal or mediastinal surgery, pregnancy, age younger than 18 years, inability to toler-ate general anesthesia, a body mass index (BMI) greater than 40, presence of a hiatal hernia (> 3 cm) or a need for an associated intra-abdominal procedure. Previous endoscopic dilation or botulinum toxin injection was not an exclusion criterion.

Preoperative assessment included the Eckhardt ques-tionnaire, upper endoscopy, barium swallow, esophageal manometry and 24-hour pH when feasible. Patients were instructed to consume only clear liquids for 48 hours before their surgery date. A 5-day course of nystatin (500 000 units 3 times/d, swish and swallow) was given before their surgery. Only a mechanical com-pressive device was used for deep vein thrombosis pro-phylaxis. A second-generation cephalosporin was given preoperatively.

Surgical technique

Patients were under general anesthesia and placed in the supine position with the left arm tucked. A single-channel high-definition flexible gastroscope (GIF-H180, Olympus Canada) with carbon dioxide insuf�a-tion was used. An oblique dissecting cap was �tted onto the gastroscope. Gastroscopy was performed and the esophagus suctioned clear. A submucosal lift (10–15 mL of a mixture of 0.2 mg/mL indigo carmine, 5 µg/mL epinephrine and 0.9% saline) was performed 10 cm above the gastroesophageal junction on the anterior surface of the esophagus (Fig. 1A). A triangle-tip endo-scopic knife (Olympus Canada) was used to make a 2 cm longitudinal mucosotomy (Fig. 1B). The endo-scope was manoeuvred into the submucosal space. The submucosal tunnel was created using the triangle-tip knife (Fig. 1C). The submucosal tunnel extended 2 cm distal to the gastroesophageal junction onto the lesser curvature of the stomach (Fig. 1D). After completion of the submucosal tunnel, the gastroscope was removed and inserted into the gastric lumen to con�rm adequate extent of the submucosal tunnel. Presence of gastric mucosal blanching identified on a retroflexed endo-scopic view in the stomach indicated adequate submu-cosal tunnel. After con�rmation, the gastroscope was reinserted into the submucosal tunnel, and a selective myotomy of only the inner, circular muscle �bres was performed using the triangle-tip knife (Olympus Can-ada; Fig. 1E). The myotomy was started 2–3 cm distal to the mucusotomy site. After successful completion of the myotomy the mucosotomy was closed using endo-scopic clips (QuickClip, Olympus, Canada; Fig. 1F).

Postoperative routine

We performed a water-soluble contrast study on postop-erative day 1. A clear liquid diet was started after the contrast study was read. Narcotic usage was recorded. Patients were scheduled for a follow-up appointment 2 weeks postsurgery. A dietician instructed the patients on diet advancement before discharge from hospital.

RESULTS

We included 10 patients in our pilot study. All patients underwent successful POEM. Preoperative patient and manometric characteristics are shown in Table 1. Seven (70%) patients had prior endoscopic treatments for achalasia. We found that performing POEM in the patient who had a previous botulinum toxin injection was more technically challenging owing to scarring in the submucosal layer at the level of the LES. The dura-tion of surgery for this patient was 182 minutes com-pared with a mean duration of 141 minutes for the


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group. Patients who underwent previous balloon dilata-tion were technically equivalent to patients who did not have previous treatments. Seven (70%) patients had an American Society of Anaesthesiologists (ASA) physical status score of 3, and 3 (30%) patients had an ASA score of 2.

There were no deaths or mobidities among our patients. One patient had clinically important intra-operative capnoperitoneum that required decompression via a Veress needle placed in the left upper quadrant. Another patient experienced a transient, intraoperative episode of hypotension that resolved with endoscopic decompression of the stomach. A third patient had a fever (38° C) on postoperative day 1 that resolved spontaneously.

All patients had a normal water-soluble gastrograf�n swallows on postoperative day 1. Perioperative outcomes

are shown in Table 2. Six (60%) patients took no narcot-ics postoperatively. Three (30%) patients took 1 dose of narcotic and 1 (10%) patient took 3 doses of narcotics. Nine (90%) patients were discharged on postoperative day 1, and 1 patient stayed in hospital 2 days. No com-plications were reported by patients during their 2-week follow-up visit. All patients reported substantial symp-tomatic improvement.

DISCUSSION

The �rst endoscopic division of the lower esophageal sphincter was described by Ortega and colleagues in 1980.11 However, it wasn’t until Pasricha and col-leagues12 described an endoscopic submucosal myotomy in a pig model and, subsequently, Inoue and colleagues13

Fig. 1: Steps of the per oral endoscopic myotomy (POEM) procedure.

A B

C D

E F

Muscle �bres

Mucosa


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described the �rst human study of endoscopic submuco-sal myotomy for achalasia that interest in this technique gained attention. Since the �rst human report, investi-gators from the United States, Europe and Asia have reported their results using the POEM technique.

Most published outcomes using POEM have been positive. Several recent reviews have shown excellent operative and short-term outcomes.14–16 No deaths from POEM have been reported in the more than 1000 cases performed. We had no clinically important complications in our pilot study. We did have 1 patient with intraopera-tive capnoperitoneum that required decompression, and several patients showed a small capnoperitoneum on postoperative day 1 water-soluble contrast. This high-lights the need to use carbon dioxide insuf�ation, as air does tract beyond the thin longitudinal muscle �bres of the esophagus and stomach. If regular air is used for insuf�ation, a clinically important pneumothorax, pneu-momediastinum or pneumoperitoneum may occur. These excellent outcomes are likely a result of careful patient selection, surgeons and gastroenterologists who are expert endoscopists and physicians undergoing a rigorous systematic approach to learn POEM.

POEM is an advanced therapeutic endoscopic pro-cedure requiring advanced endoscopic skills. Our group had previous advanced endoscopic skills, including stent placement, advanced clipping and endoscopic mucosal resection. In preparation for undertaking the POEM study, we were deliberate, conservative and systematic in

our approach. One of us (D.H.) travelled to the institu-tion of a high-volume POEM surgeon (Dr. Lee Swanstrom, Portland, Oregon, USA) to observe how the team was set up and to learn technical skills. He then completed a formal course in POEM (American Society for Gastrointestinal Endoscopy, 2013). We then per-formed 2 animal models to familiarize ourselves with the submucosal anatomy and master instrumentation. We obtained REB approval for our pilot study, and an expert (Dr. Lee Swanstrom) who had performed more than 100 POEM procedures assisted us in our �rst 2 cases. Other investigators have followed similar, systematic approaches to introducing POEM at their institution.17 We feel participation in animal laboratories and expert mentoring are necessary when introducing new, tech-nically demanding procedures, such as POEM.

A criticism of POEM has been the potential risk of reflux. Unlike Heller myotomy, the angle of His and esophageal attachments are not disrupted in POEM, obviating the need for an antire�ux procedure. Data sug-gest that a limited hiatal dissection with preservation of hiatal anatomy may result in lower re�ux.18 Bhayani and colleagues19 recently described their comparative study on laparoscopic Heller myotomy plus fundoplication ver-sus POEM. At 6 months, they found no statistical differ-ence in abnormal acid exposure between the 2 proced-ures. Some have criticized the high percentage of POEM patients with abnormal acid exposure on 24-hour testing (39%) in their study. A second comparative study between POEM and laparoscopic Heller myotomy plus fundoplication found similar rates of re�ux postopera-tively.20 Advocates of POEM have suggested that the rates of re�ux following a Heller myotomy plus fundopli-cation are just as high as the rates found following POEM.21,22 This would suggest that, in the short-term, POEM produces the same rates of reflux as a Heller myotomy with fundoplication.

Another concern has been that division of only the cir-cular muscle �bres in the POEM procedure may limit its effectiveness in alleviating the symptoms of achalasia as compared with division of all muscle �bres in a standard Heller myotomy. Yet a recent comparative study on endoscopic full-thickness myotomy versus circular muscle myotomy found no clinical or manometric differences.23 This suggests that circular muscle myotomy alone is suf-�cient for excellent outcomes.

Limitations

Our study has some limitations. The �rst is our small sample of 10 patients. Low prevalence of achalasia will require several institutions specializing in esophageal motility disorders to collaborate to achieve adequate numbers. Another limitation is the lack of longer-term data regarding the rate of re�ux. We will continue to

Table 1. Patient and manometry characteristics

CharacteristicMean ± SD or no. (%)

Age, yr 53.8 ± 10.8

Male sex 7 (70%)

Previous treatment

None 3 (30%)

Balloon dilatation 6 (60%)

Botulinum toxin 1 (10%)

Preoperative Eckhardt scores (< 3 is normal) 8.1 ± 2.4

LES resting pressure 32.3 ± 9.2

LES residual pressure 20.8 ± 5.3

LES = lower esophageal sphincter; SD = standard deviation.

Table 2. Perioperative outcomes of POEM

Outcome Mean ± SD

Duration of surgery, min 141.3 ± 43.7

Submucosal tunnel length, cm 12 ± 1.1

Myotomy length, cm 8.9 ± 1.1

No. of clips to close mucosotomy 7.5 ± 2.1

LOS, d 1.1 ± 0.3

Postoperative (2 wk) Eckhardt score (< 3 is normal) 0.9 ± 1.2

LOS = length of stay in hospital; POEM = per oral endoscopic myotomy; SD = standard deviation.


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accrue patients prospectively and are currently obtaining esophageal manometry, 24-hour pH, barium swallow and upper endoscopy at 6 months for all patients.

CONCLUSION

To our knowledge, this is the first published series of POEM in Canada. Even in the early learning curve, POEM is safe and feasible to treat esophageal achalasia. Multi-institutional, collaborative studies are required to assess the long-term results of POEM.Af�liations: All authors are from the Department of Surgery, McMaster University, Hamilton, Ont.


Contributors: D. Hong, R. Pescarus and M. Anvari designed the study. D. Hong, R. Khan, L. Ambrosini and M. Cadeddu acquired the data, which D. Hong and M. Anvari analyzed. D. Hong and L. Ambrosini wrote the article, which all authors reviewed and approved for publication.

References

1. Maradey-Romero C, Gabbard S, Fass R. Treatment of esophageal motility disorders based on the chicago classi�cation. Curr Treat Options Gastroenterol 2014;12:441-55.

2. Schoenberg, MB, Marx S, Kersten JF, et al. Laparoscopic Heller myotomy versus endoscopic balloon dilatation for the treatment of ac halasia: a network meta-analysis. Ann Surg 2013;258:943-52.

3. Yaghoobi M, Mayrand S, Martel M, et al. Laparoscopic Heller’s myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials. Gastrointest Endosc 2013;78:468-75.

4. Weber CE, Davis CS, Kramer HJ, et al. Medium and long-term out-comes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech 2012;22:289-96.

5. El Hak NG, Hamdy E, Abdalla T, et al. Laparoscopic Heller myotomy for achalasia: analysis of successes and failures. Hepatogastroenterology 2012;59:1450-4.

6. Mattioli S, Ruffato A, Lugaresi M, et al. Long-term results of the Heller-Dor operation with intraoperative manometry for the treatment of esophageal achalasia. J Thorac Cardiovasc Surg 2010;140:962-9.

7. Swanstrom LL, Kurian A, Dunst CM, et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012;256:659-67.

8. Minami H, Isomoto H, Yamaguchi N, et al. Peroral endoscopic myotomy for esophageal achalasia: clinical impact of 28 cases. Dig Endosc 2014;26:43-51.

9. Li QL, Chen WF, Zhou PH, et al. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013;217:442-51.

10. Von Renteln D, Fuchs KH, Fockens P, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013;145:309-11.

11. Ortega JA, Madureri V, Perez I. Endoscopic myotomy in the treatment of achalasia. Gastrointest Endosc 1980;26:8-10.

12. Pasricha PJ, Hawari R, Ahmet I, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treat-ment of achalasia. Endoscopy 2007;39:761-4.

13. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myot-omy (POEM) for esophageal achalasia. Endoscopy 2010;42:265-71.

14. Stavropoulos SN, Desilets DJ, Fuchs KH, et al. Per-oral endoscopic myotomy white paper summary. Surg Endosc 2014;28:2005-19.

15. Pescarus R, Shlomovitz E, Swanstrom LL. Per-oral endoscopic myotomy (POEM) for esophageal achalasia. Curr Gastroenterol Rep 2014;16:369.

16. Stavropoulos SN, Modayil RJ, Friedel D, et al. The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc 2013;27:3322-38.

17. Perretta S, Dallemagne B, Marescaux J. Steps to POEM: introduction of a new technique at the IRCAD. Surg Innov 2012;19:216-220.

18. Simic AP, Radovanovi NS, Skrobi OM, et al. Signi�cance of limited hiatal dissection in surgery for achalasia. J Gastrointest Surg 2010;14:587-93.

19. Bhayani NH, Kurian AA, Dunst CM, et al. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg 2014;259:1098-103.

20. Teitelbaum EN, Rajeswaran S, Zhang R, et al. Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a sim-ilar a similar short-term anatomic and functional effect. Surgery 2013;154:885-91.

21. Khajanchee YS, Kanneganti S, Leatherwood AE, et al. Laparoscopic Heller myotomy with Toupet fundoplication: outcomes predictors in 121 consecutive patients. Arch Surg 2005;140:827-33.

22. Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc 2012;26:18-26.

23. Li Ql, Chen W, Zhou P, et al. Per oral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013;217:442-51.



Early experience with robotic pancreatic surgery in a Canadian institution

Background: Pancreatic resections have traditionally been associated with sub-stantial morbidity and mortality. The robotic platform is believed to improve tech-nical aspects of the procedure while offering minimally invasive benefits. We sought to determine the safety and feasibility of the �rst robotic pancreaticoduode-nectomies performed at our institution.

Methods: We retrospectively reviewed data on all patients who underwent robotic-assisted pancreaticoduodenectomy (RAPD) between July 2010 and June 2014 and compared them to outcomes of patients undergoing hybrid laparoscopic pancreaticoduodenectomies (HLAPD) during the same time period.

Results: Fifteen patients were scheduled for RAPD; 2 were converted to an open approach and 1 to a mini-laparotomy during the laparoscopic portion of the proced-ure. Patients who had RAPD (n = 12) had a median duration of surgery of 596.6 (range 509–799) minutes, estimated blood loss of 275 (range 50–1000) mL and median length of stay of 7.5 (range 5–57) days. Mean total opioid use up to postop-erative day 7 was 142.599 ± 68.2 versus 176.9 ± 112.7 mg equivalents of intravenous morphine for RAPD and HLAPD, respectively. There was no signi�cant difference between RAPD and HLAPD in any parameters, highlighting the safety and feasibil-ity of a step-wise minimally invasive learning platform. Most patients in the RAPD group had malignant pathology (88.2%). Oncologic outcomes were maintained with no signi�cant difference in ability to resect lymph nodes or achieve negative mar-gins. There were 4 (28.5%) Clavien I-II complications and 3 (29.4%) Clavien III–IV complications, 2 of which required readmission. There were no reported deaths at 90 days. Complication, pancreatic leak and mortality rates did not differ signi�-cantly from our laparoscopic experience.

Conclusion: Outcomes of RAPD and HLAPD were comparable at our centre, even during the early stages of our learning curve. These results also highlight the safety, feasibility and patient bene�ts of a step-wise transition from open to hybrid to fully robotic pancreaticoduodenectomies in a high-volume academic centre.

Contexte : L’ablation du pancréas a de tout temps été associée à une morbidité et une mortalité importantes. Le recours à une plateforme assistée par robot devrait vraisemblablement améliorer les aspects techniques de l’intervention et offrir en même temps les avantages d’une intervention minimalement effractive. Nous avons voulu déterminer l’innocuité et la faisabilité des premières pancréatoduodénecto-mies assistées par robot effectuées dans notre établissement.

Méthodes : Nous avons passé en revue de manière rétrospective les données concer-nant tous les patients ayant subi une pancréatoduodénectomie assistée par robot (PDAR) entre juillet 2010 et juin 2014 et nous les avons comparées aux résultats enregistrés chez les patients ayant subi une pancréatoduodénectomie laparoscopique hybride (PDLH) au cours de la même période.

Résultats : Quinze patients ont été pressentis pour une PDAR; 2 ont plutôt subi une intervention ouverte et 1 a subi une mini-laparotomie durant la portion lapa-roscopique de l’intervention. Chez les patients soumis à la PDAR (n = 12), la durée médiane de la chirurgie a été de 596,6 (plage de 509 à 799) minutes, les pertes san-guines estimées ont été de 275 (plage de 50 à 1000) mL et la durée médiane du séjour hospitalier a été de 7,5 (plage de 5 à 57) jours. L’utilisation totale moyenne d’opioïdes jusqu’au septième jour postopératoire a été de 142,599 ± 68,2 mg équiva-lents de morphine intraveineuse contre 176,9 ± 112,7 pour la PDAR et la PDLH, respectivement. On n’a noté aucune différence signi�cative entre la PDAR et la

Sabrina Piedimonte, MDCM, MSc Yifan Wang, MDCM Simon Bergman, MD, MSc Tsafrir Vanounou, MD, MBA

This paper was presented as a poster presentation at the SAGES Annual Meet-ing, Baltimore MD, Apr. 17–20, 2013, and as a poster presentation at the Canadian Surgery Forum, Ottawa, ON, Sept. 19–21, 2013.

Accepted for publication June 9, 2015

Correspondence to: T. Vanounou Jewish General Hospital, Rm A5-15 3755 Cote Ste Catherine Rd Montreal QC H3T 1E2 [email protected]

DOI: 10.1503/cjs.003815


early-piedimonte.indd 394 2015-11-10 1:36 PM

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S urgical procedures of the pancreas have tradition-ally been associated with substantial morbidity and mortality.1 Minimizing morbidity has been one of

the major factors initiating a shift toward minimally inva-sive (MIS) approaches in pancreatic resections. While still accounting for a minority of all pancreatic resections, MIS techniques now account for 1 of every 13 pancreatic resec-tions.2 Three recent meta-analyses, including 1 using data from the Nationwide Inpatient Sample database, report that minimally invasive hepatobiliary surgery has consist-ently been associated with decreased blood loss and intra-operative complications as well as decreased length of stay in hospital (LOS) and increased lymph node harvest. These benefits have been achieved while maintaining comparable complication and leak rates to open resections despite increased duration of surgery.2,3

Beyond the traditional laparoscopic techniques, robotics offer additional advantages with increased magni�cation, depth, range of motion and dexterity.4 Giulianotti and col-leagues5 �rst reported the outcomes of 8 robotic-assisted pancreaticoduodenectomies (RAPD) in 2003, demonstrat-ing safety and feasibility, with morbidity and mortality com-parable to open surgery.5 Because of the robotic platform’s versatility and relatively rapid learning curve, several groups worldwide have gained ease in the procedure and have unanimously reported decreased conversion rates, decreased blood loss and ability to maintain oncologic outcomes.6 In 2011, a meta-analysis reported that more than 1 in 5 of all MIS cases were performed using a robotic approach, with the majority of robotic hepatopancreatobiliary (HPB) cases (75%) being performed on the pancreas, with increasing pancreaticoduodenectomies performed over time.2 Despite this progress, robotic pancreatic surgery continues to account for a very small proportion of overall cases per-formed worldwide.

In Canada, the experience with the robotic platform in pancreatic resections is forthcoming, and to our knowledge no cases have yet been reported in the literature. Certain high-volume Canadian institutions have begun to transition into laparoscopic techniques with encouraging results. We

previously reported outcomes for hybrid laparoscopic pan-creaticoduodenectomies (HLAPD), which showed signi�-cantly lower intraoperative blood loss and shorter LOS com-pared with open surgery while maintaining comparable results for oncologic outcomes and complications. This ex perience has provided us with the tools needed to adopt an MIS approach for nearly all pancreatic surgery at our centre within well-established inclusion criteria.7 Furthermore, the experience with the hybrid approach, where the pancreatico-duodenectomy resection is completed laparoscopically and the reconstruction completed through a mini- laparotomy, provided our group with the necessary preparation to transi-tion from an open reconstruction to a robotic reconstruction, as previously described by Zureikat and colleagues.6

The purpose of the present study was to determine the safety and feasibility of robotic pancreatic surgeries during the initial phase of our institutional learning curve and to compare these results to our previously validated outcomes for HLAPD.

METHODS

This is a retrospective study of patients who underwent RAPD between July 2010 and June 2014. We compared the results with the outcomes for patients undergoing HLAPD. All procedures were performed by the same 2 attending staff surgeons (T.V. and S.B.).

Patient selection

All patients underwent preoperative high-resolution imaging (either computed tomography [CT], magnetic resonance imaging [MRI], or both). Patients were selected for a minimally invasive approach (RAPD or HLAPD) based primarily on tumour characteristics: localized tumours with no vascular invasion. A clear, fat plane had to be present around all arterial and venous structures, including the superior mesenteric artery (SMA), superior mesenteric vein (SMV) and common hepatic artery on preoperative high-resolution CT imaging. Any patient with suspected vascular

PDLH au plan des paramètres, ce qui souligne l’innocuité et la faisabilité d’une plateforme d’apprentissage séquentielle minimalement effractive. La plupart des patients du groupe soumis à la PDAR étaient atteints d’un cancer (88,2 %). Les paramètres oncologiques se sont maintenus, sans différence signi�cative quant à la capacité de réséquer les ganglions lymphatiques ou d’obtenir des marges négatives. On a dénombré 4 (28,5 %) complications de stade I–II et 3 (29,4 %) de stade III–IV selon la classi�cation de Clavien; 2 de ces dernières ont nécessité une réadmission. On n’a déploré aucun décès à 90 jours. Les taux de complications, de fuite pancréa-tique et de mortalité n’ont pas différé signi�cativement par rapport à nos interven-tions laparoscopiques.

Conclusion : Les résultats de la PDAR et de la PDLH ont été comparables dans notre établissement, même aux premières étapes de notre courbe d’apprentissage. De tels résultats soulignent l’innocuité, la faisabilité et les bienfaits pour les patients d’une tran-sition graduelle des pancréatoduodénectomies ouvertes, hybrides puis entièrement assistées par robot dans un centre universitaire traitant de forts volumes de patients.


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invasion underwent an open pancreaticoduodenectomy (OPD). In cases of equivocal vascular invasion, our group erred on the side of attempting a laparoscopic resection and then converting to an open resection rather than opting for an upfront open approach. This was not an intention to treat protocol, therefore all patients who were converted to open or mini-laparotomy before the docking of the robot for the reconstruction were not included in the RAPD group, as no robotic reconstruction was undertaken to justify inclusion into this group. We previously reported that patients in the HLAPD group who were converted to the OPD group did not contribute to worse outcomes for this group or favour outcomes of the minimally invasive group.7 Thus, any patient in whom a conversion to an open operation was required was included in the open group. All patients for whom a mini-laparotomy was used for reconstruction following a totally laparoscopic resection were included in the HLAPD group. Of note the choice of HLAPD versus RAPD during the study period was purely dictated by robot availability.

Data collection

Data were abstracted from the medical records and the surgical clinic notes and limited by the patient chart reporting. A blood loss reported as “nil” in the patient chart was estimated to be 50 mL.

We recorded the following demographic and clinical characteristics: age, sex and American Society of Anaesthesi-

ologists (ASA) class. We also collected the following opera-tive factors: duration of surgery, estimated blood loss, posi-tive margin rate, positive lymph node rate, number of lymph nodes harvested, intraoperative transfusion rate and tumour size. We reported complications up to postoperative day 90 based on the Clavien Classi�cation System;8 pancreatic �s-tula rates as per the postoperative pancreatic �stula interna-tional study group (ISPGF) criteria outlined in Appendix 1, available at canjsurg.ca;9 and delayed gastric emptying, as de�ned by the grading scheme outlined in Appendix 1.10

Readmission, reoperation and mortality at 90 days were also reported.

Operative technique

The following outlines the operative steps for the laparo-scopic portion of the RAPD. 1. The patient is prepared and draped in a sterile fashion

and positioned in a dorsal lithotomy postion. Place-ment of the trocars are illustrated in Figure 1.

2. Diagnostic laparascopy is performed.3. The gastrocolic ligament is divided from the midpor-

tion of the greater curvature to the right side, identi-fying the plane between the gastroepiploic omentum and the transverse mesocolon. The gastroepiploic vein is identi�ed and traced back to the level of the infrapancreatic SMV and then divided.

4. The right colon is mobilized and the duodenum kocherized until the ligament of Treitz is released.

Fig. 1. Patient and trocar position for (A) laparoscopic resection and (B) robotic reconstruction. *Liver retractor; A1 and A2 = assistant laparoscopic port; C = camera port (10 mm); R1, R2 and R3 = robotic port (8 mm); S1 and S2 = surgeon laparoscopic port (5 mm).

Laparoscopic resection

S1

* *

5 mmA1

10 mm

C

5 mmS2

5 mm A2 A2 10 mm

R3

8 mmR1

8 mmC

10 mmA1

10 mm

10 mm

R28 mm

Robotic reconstruction

A B


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5. The jejunum is brought back toward the right side of the abdomen and divided using a linear stapler. The mesen-tery of the proximal jejunum and duodenum is divided.

6. The distal stomach is divided using a linear stapler.7. The common hepatic node is identi�ed and sampled.8 The gastroduodenal artery is divided using a vascular

linear stapler.9. The retropancreatic tunnel is developed above the

SMV/portal vein (PV), and a Penrose drain is used to encircle the pancreas.

10. A complete hepatic hilar lymphadenectomy is per-formed, including all retropancreatic and periportal nodes.

11. A retrograde cholecystectomy is performed.12. The common bile duct is transected above the junc-

tion with the cystic duct using a linear stapler.13. The pancreas is then divided using bipolar energy.14. The uncinate process dissection is performed by divid-

ing the venous branches coming off the SMV as well as the �rst jejunal branches with clips or bipolar energy. The SMA is identi�ed inferiorly, a subadventitial plane is developed, and the uncinate process is divided along this plane in a cephalad direction.

15. The specimen is extracted through a Pfanenstiel incision. This incision is closed and pneumoperito-neum is reobtained.

16. The proximal jejunum, onto which all reconstructions are performed, is brought up in the right upper quad-rant. A side-to-side antecolic retrogastric loop gastroje-junostomy is created.

The robotic portion is performed as outlined below. Patient and trocar positioning are outlined in Figure 1B.1. The robotic trocars are placed and the robot is then

docked.2. A duct-to-mucosa pancreaticojejunostomy is per-

formed in a Blumgart fashion.11 Using a 3–0 silk, sev-eral stitches are placed through the pancreas and back through the jejunum. Three duct-to-mucosa stitches using 4–0 suture are placed along the 9, 6 and 3 o’clock positions.

3. A pediatric feeding tube is placed in the pancreatic duct as a stent. The posterior duct-to-mucosa stiches and Blumgart stitches are tied. The anterior ductal mucosa stitches are completed using 4–0 suture. The needles left on the Blumgart stitches are then used to dunk the pancreaticojejunostomy.

4. The hepaticojejunostomy is performed in an inter-rupted fashion using 4–0 suture.

5. Two drains are left deep and super�cial to the pancre-atic and biliary anastomoses.


We used SPSS software version 22.0 to perform all data analyses. We chose to report medians over means for all

parameters except for postoperative opioid use, given non-normally distributed numbers in a population with out-liers. For reported medians, we used a Mann–Whitney U test to determine significance between RAPD and HLAPD. We performed a χ2 test to determine signi�-cance of categorical values. We used Microsoft Excel to generate a graph of postoperative opioid use.

RESULTS

Between July 2010 and June 2014, 19 patients were scheduled to undergo robotic pancreaticoduodenec-tomies; 4 were found to have metastatic disease upon diagnostic laparoscopy and thus were excluded from the present analysis. Among the 15 remaining patients, 2 were converted to an open approach before the docking of the robot: 1 owing to adherence between the tumour and the common bile duct and right hepatic artery and 1 owing to a puckered mesocolon and tumour invasion into the SMV. A third patient, who had familial polyp-osis, was converted to a mini-laparotomy owing to ad hesions precluding mobil ization at the level of the liga-ment of Treitz. These 3 patients were not included in the present analysis, as their conversions were not related to any aspect of the robotic reconstruction but rather to intraoperative �ndings that could not be predicted preop-eratively and for which a minimally invasive approach was deemed unsafe.

Twelve patients successfully underwent RAPD and were included in the present analysis. The median age of patients was 71 (range 26–80) years, and the median duration of sur-gery was 596.6 (509–799) min. There was a net improve-ment in the learning curve; patients in the second half of the study period had a median duration of surgery of 567 (range 509–650) min compared with 668.5 (range 555–799) min for those in the �rst half of the study period. The median estimated blood loss was 275 (300–1000) mL. There was 1 intraoperative complication with injury to the SMV dur-ing the laparoscopic portion of the procedure, which was immediately repaired laparoscopically. Demographic and operative �ndings are summarized in Table 1. Fourteen patients underwent HLAPD during the same timeframe. The choice of HLAPD versus RAPD was mostly dictated by robot availability. There was no signi�cant difference between the RAPD and the HLAPD groups.

There was no signi�cant difference in oncologic out-comes between the RAPD and HLAPD groups (Table 2). The majority of patients (88.5%) had malignant pathology. The most common pathology for RAPD was pancreatic ductal adenocarcinoma, accounting for 58.3% of cases, fol-lowed by pancreatic neuroendocrine tumours (16.7%), cholangiocarcinoma (8.3%), duodenal gastrointestinal stromal tumour (GIST; 8.3%) and intraepithelial neoplasia (8.3%). The R0 resection rate was 91.7%, and the median number of harvested lymph nodes was 22.5 (range 4–44),


RECHERCHE


58.3% of which were positive. The median tumour size was 2.85 cm. There was no recurrence at 90 days.

The median LOS was 7.5 (range 5–57) days in the RAPD group, as compared to 8 (range 6–14) days in the HLAPD group (p = 0.78), and mean total 7-day opioid use was 142.599 ± 68.2 mg of intravenous morphine equivalents in the RAPD group versus 176.9 ± 112.7 mg of intravenous morphine equivalents in the HLAPD group (Fig. 2). There was no signi�cant difference between 90-day complication and pancreatic leak rates. Four patients had Clavien I–II complications that were conservatively managed (Table 3). Three patients had Clavien III–IV complications, 2 of which

required admission to the intensive care unit; there was 1 reoperation for transverse colon perforation and peritonitis and 1 case of sepsis from pancreatic leak requiring intubation and CT-guided drainage. The third patient was readmitted with delirium secondary to a biliary leak and intra-abdominal abscess and required percutaneous drainage. There were no deaths within 90 days.

DISCUSSION

The versatility of the robotic platform to successfully per-form well-selected pancreatic procedures with a low

Table 1. Patient demographic and perioperative characteristics

Group; mean (range)*

Characteristic RAPD HLAPD p value†

Patient, no. 12 14

Age, yr 71 (26–80) 69 (49–88) 0.95

Sex, male:female, % 50:50 78.6:21.4 0.31

ASA score 2 (2–3) 2 (2–3) 0.07

Duration of surgery, min 596.5 (509–799) 592.5 (407–779) 0.78

Estimated blood loss, mL 275 (50–1000) 400 (100–4000) 0.26

Intraoperative blood transfusion, no. (%)

1 (8.3) 5 (35.7) 0.05

Total 7-day analgesic use, mg IV, mean ± SD

142.599 ± 68.2 176.9 ± 112.7 0.35

LOS, d 7.5 (5–57) 8 (6–14) 0.78

90-day mortality, % 0% 7.1% 0.14

ASA = American Society of Anaesthesiologists; HLAPD = hybrid laparoscopy-assisted pancreaticoduodenec-tomy; IV = intravenous; LOS = length of stay; RAPD = robotic-assisted pancreaticoduodenectomy; SD = standard deviation. *Unless indicated otherwise. †Mann–Whitney U test.

Table 2. Pathologic and oncologic outcomes

Group; mean [range] or no. (%)

Outcome RAPD (n = 12) HLAPD (n = 16) p value*

Tumour size, cm 2.85 [1.2–7] 3.4 [1.8–4.2] 0.98

Positive resection margin 1 (8.3) 3 (18.8) 0.66

Lymph node harvest 22.5 [4–44] 22 [13–56] 0.55

Positive lymph nodes 7 (58.3) 9 (56.3) 0.40

Malignant 11 (91.7) 12 (75.0) 0.23

Pancreatic adenocarcinoma 6 (50.0) 10 (62.5) —

Ampullary adenocarcinoma 1 (8.3) 1 (6.3) —

Neuroendocrine tumour 2 (16.7) 1 (6.3) —

Cholangeocarcinoma 1 (8.3) 0 —

Duodenal GIST 1 (8.3) 0 —

Benign 1 (8.3) 2 (12.5) 0.13

IPMN 0 1 (6.3) —

Pan-IN 1 (8.3) 0 —

Duodenal polyp 0 1 (6.3) —

Perforated gastric ulcer 0 0 —

Familial polyposis related tubular adenomas

0 0 —

GIST = gastrointestinal stromal tumour; HLAPD = hybrid laparoscopy-assisted pancreaticoduodenectomy; IPMN = intraductal papillary mucinous neoplasm; Pan-IN = pancreatic intraepithelial neoplasia; RAPD = robotic-assisted pancreaticoduodenectomy. *Mann–Whitney U test.


RESEARCH


conversion rate is a major advantage when transitioning from an open to a minimally invasive approach.6 In doing so, fundamental surgical principles must be maintained: safe dissection, ability to control hemorrhage, achieving negative margins and focusing on meticulous reconstruc-tion.6 To date, Zureikat and colleagues6 have provided the lar gest body of evidence for robotic pancreatic resections performed in a single centre (n = 250), including 132 pan-creaticoduodenectomies, 83 distal pancreatectomies, 13 central pancreatectomies, 10 enucleations, 5 total pan-

createctomies, 4 Appleby procedures, and 3 Frey proced-ures. In regards to RAPD, their �ndings support low com-plication rates (14% and 6% for Clavien III and Clavien IV complications, respectively) and mortality (2% at 90 days), with minimal conversion (6%). Their �ndings emphasize the ability to successfully complete complex pancreatic resections and reconstructions in a minimally invasive fashion, provided a minimal learning curve of 60–80 cases.6 They demonstrated that with increasing experience robotics has replaced open as the most com-mon approach to pancreatic resections at their institution since the transition in 2008.

Similarly, our centre began performing robotic-assisted pancreatic resections in July 2010. We have adopted a more diversi�ed robotic-assisted laparoscopic approach, in con-trast to a purely robotic approach as described by Zureikat and colleagues.6 We complete the entire resection laparo-scopically and also undertake the gastrojejunostomy laparo-scopically. We use the robotic platform only for the pancre-aticojejunostomy and hepatojejunostomy — steps for which we believe the robot adds the most value relative to a purely laparoscopic or hybrid approach. Our experience previously gained performing HLAPD has facilitated a step-wise intro-duction of minimally invasive techniques and eased our transition from laparoscopic to robotic techniques. In our previous study comparing 13 HLAPD and 20 open cases, with similar demographic parameters, we found signi�cantly decreased blood loss (450 mL v. 1000 mL, p = 0.023) and postoperative LOS (8 v. 12 d, p = 0.025), with no difference in complication rates, pancreatic leak rates or mortality.7 This initial experience with a hybrid approach allowed us not only to master the laparoscopic resection, which is iden-tical to the resection performed in RAPD, but also to focus on the reconstruction phase and maximize the robotic plat-form’s advantages for magni�cation, stability and increased ability for challenging suturing of small-calibre ducts.6 As such, the present study compares outcomes of RAPD with HLAPD to truly determine if there is any difference in the robotic reconstruction as compared with a hybrid approach and if it is safe and feasible to incorporate it in a centre with previous laparoscopic experience.

Though we initially expected to see an impact of robotics when performing enteric anastomosis, there was no signi�-cant difference in the pancreatic leak rate as compared with HLAPD; 25% of the RAPD patients experienced a high-grade (B or C) leak as compared with 12.5% in the HLAPD group. This is consistent with the range for RAPD reported in the literature (4%–38%; Table 4).6 Our operative approach to the pancreatic remnant involved a duct-to-mucosa pancreaticojejunostomy in a Blumgart fashion with placement of a pediatric feeding tube as a stent in an attempt to reduce pancreatic leaks.18 Zureikat and colleagues6 used the same approach and reported a 21% leak rate among all patients undergoing robotic duct-to-mucosa pancreaticoje-junostomies, which is less than other groups that opted for

Fig. 2. Postoperative analgesic requirements. Data points from hybrid laparoscopy-assisted pancreaticoduodenectomy (HLAPD) and open pancreaticoduodenectomy (OPD) patients extracted from the study by Wang and colleagues.7 POD = postoperative day; RAPD = robotic-assisted pancreaticoduodenectomy.

Postoperative analgesic requirements

Mea

n m

orph

ine

equi

vale

nts

(mgI

V)

60.00

50.00

40.00

30.00

20.00

10.00

0.00

35.25 39.29

22.872 20.66

10.69 11.28 10.74

RAPD

HLAPD

OPD

POD # 1 2 3 4 5 6 7

Table 3. Ninety-day complication rate

Group; no. (%)

Complication RAPD (n = 12) HLAPD (n = 16) p value*

Clavien I–II† 4 (33) 4 (25.0) 0.63

Intra-abdominal abscess 0 1 (6.3) —

Wound infection 1 (8.3) 0 —

Delayed gastric emptying 2 (16.7) 2 (12.5) —

Pneumonia 0 0 —

Hypotension 0 1 (6.3) —

Wound dehiscence 1 (8.3) 0 —

Clavien III–IV‡ 3 (25) 4 (25.0) 0.07

Intra-abdominal abscess 2 (16.7) 2 (12.5) —

Anastomotic breakdown 0 1 (6.3) —

Portal vein thrombosis 0 0 —

Postoperative hemorrhage 0 0 —

Peritonitis/colon perforation 1 (8.3) 0 —

Acute myocardial infarction 0 0 —

Bowel ischemia 0 1 (6.3) —

Pancreatic �stula 4 (33.0) 5 (31.3) 0.12

Grade A 1 (8.3) 3 (18.8) —

Grade B 3 (25.0) 2 (12.5) —

HLAPD = hybrid laparoscopy-assisted pancreaticoduodenectomy; RAPD = robotic- assisted pancreaticoduodenectomy. *Calculated using the χ2 test. †Not necessitating radiological, endoscopic or operative intervention and not causing organ failure ‡Necessitating radiological, endoscopic or operative intervention and/or causing organ failure.


RECHERCHE


alternative measures, such as sclerosis with fibrin glue.11 Giulianotti and colleagues1 reported a 36.5% pancreatic �stula rate in the RAPD patients who underwent sclerosis compared with those who underwent anastomosis (21%). Given multiple failed attempts to decrease pancreatic leak rates reported in the literature and in light of the present �ndings, there may be an inherent pancreatic leak rate that must be accepted and managed early, despite minimally invasive approaches. That being said, our leak rate is well within the norms reported in the literature and is in fact below that reported by the largest centre performing RAPD despite the early phase of our learning curve.6

Early management of these leaks, including drain removal, would contribute to decreasing progression to intra-abdominal abscesses which accounted for 2 of the 3 major (Clavien III–IV) complications encountered in our study. One patient, who had ileus in the immediate postoper-ative course, was readmitted 2 days postdischarge with an intra-abdominal abscess requiring admission to the intensive care unit. The patient was subsequently stabilized but remained admitted for a pre- existing comorbidity unrelated to the surgical procedure. Similarly, the second patient was readmitted 2 days postdischarge with delirium secondary to intra-abdominal collection, which resolved with ultrasound-guided drainage. The third severe complication was in a patient with cholangiocarcinoma who required admission to the intensive care unit for sepsis and peritonitis secondary to transverse colon perforation. This patient underwent reoper-ation on postoperative day 7 and subsequently experienced recurrent bowel obstructions, potentially due to recurrent cholangiocarcinoma, and was eventually discharged on post-operative day 57 with no further complications. Zureikat and colleagues6 reported a drop in severe (grade III–IV) compli-cations in the later half of their learning curve (30.7% among the �rst 80 patients v. 13.7% for the late group of patients undergoing RAPD). While our centre has yet to reach this learning curve of 80 patients, our severe complication rate is comparable with that of Zureikat and colleagues during their initial experience with RAPD and is predicted to improve with experience.

Furthermore, there was no signi�cant difference in esti-mated blood loss, duration of surgery, postoperative opioid use or postoperative LOS between the RAPD and HLAPD groups in the present study. The bene�t of the robotic arms to gain access into the retroperitoneal space and provide adequate hemostasis is demonstrated by our median esti-mated blood loss of 275 mL, which is less than the rate reported in our laparoscopic cases (400 mL) and consistent with the signi�cant difference reported in the literature.4 This also re�ects our ability to control bleeding during both phases of the procedure and highlights the bene�ts of experience with both laparoscopy and robotics, so as to avoid severe complications related to hypovolemia.3 Because of less damage to surrounding vasculature, we achieved a low rate of severe complications (25% Clavien III–IV), and none was related to hypovolemia or dissemi-nated intravascular coagulation.

In addition, owing to the precision and care needed to perform these intricate resections and reconstructions with minimal complications, duration of surgery in the RAPD group (596 min) was longer than that reported for open resections3,19 but virtually identical to that in the HLAPD group (592 min) and is in the range reported in the litera-ture for RAPD (431–718 min).6,7,17 These long operations, despite our centre’s experience with the hybrid laparoscopic approach, may be in part attributed to the added complexity of malignant pathology in most of our patients (91.7%) and to the increased care in executing an adequate resection to preserve oncologic outcomes comparable to the open ex perience. Similar lymphadenectomy rates (22.5 nodes, range 4–44) were achieved as with HLAPD and in the range described by Zureikat and colleagues18 using a completely robotic approach (17 nodes, range 5–37). In addition, both attending surgeons are still within their learning curve, which is 60–80 procedures.6 In the second half of our study, we observed a median improvement of 101.5 minutes, and we predict future improvement in operative duration with increasing experience, as was reported by Zureikat and col-leagues,6 who experienced a signi�cant decrease in operative duration in their last 60 cases.6

Table 4. Early comparative experience with robotic pancreaticoduodenectomy, June 2010–July 2014

Study Country n Procedure LOS Duration, mean (range) min Pancreatic leak Complications Mortality

Giulianotti et al.5 Italy 8 PD 20 490 NA 37.5% 12.5%

Narula12 USA 5 PD 9.6 420 0 0 0

Horiguchi13 Japan 3 PD 26 703 33% NA NA

Zeh14 USA 50 PD 10 568 22% Clavien I–II (26%)Clavien III–IV (30%)

2%

Zureikat et al.15 USA 24 PD 9 512 (327–848) 21% Clavien III–IV (25%)Clavien I–II (27%)

3.3%

Chalikonda16 USA 30 PD 9.8 476 6.7% 30% 4%

Zhou17 China 8 PD 16.4 718 50% 25% 0

Zureikat et al.6 USA 132 PD 10 527 17% Clavien III: 14%Clavien IV: 6%

1.5

LOS = length of stay; NA = not available; PD = pancreaticoduodenectomy.


RESEARCH


Although long-term and quality of life data are not available in the present study, we quanti�ed the level of immediate post-operative pain based on daily analgesic requirements up to postoperative day 7. We noted minimal use of opioids with a mean of 142.599 ± 68.2 mg of intravenous morphine equiva-lents in the week following RAPD compared with 176.9 ± 112.7 mg of intravenous morphine equivalents in the HLAPD group, tapering to close to zero by postoperative day 7 in both groups; 41% of RAPD patients were weaned off by postopera-tive day 5. To our knowledge, we are the �rst to report post-operative analgesic use as an indicator of postoperative pain, but conclude decreased need for opioids in patients under-going minimally invasive than in those undergoing open pan-creaticoduodenectomy as previously reported.7 Comparative trends up to postoperative day 7 are illustrated in Figure 2. We believe that the decreased need for opioids may have directly contributed to a decreased LOS in the RAPD group (7.5 d) compared with historic open data, but there was no signi�cant difference between the RAPD and HLAPD groups.

In light of our �ndings, patients at our institution continue to be selected for a minimally invasive approach based solely on tumour characteristics on preoperative imaging. These cri-teria have not changed over time, even with increasing experi-ence. Including a patient in the RAPD or HLAPD group is not based on superiority or preference of one procedure over another but rather on robot availability on the scheduled pro-cedure date, as this resource limitation is a reality we must face in a Canadian institution. This resource limitation also restricts our ability to overcome our learning curve in a more timely fashion. Despite this constraint, our centre nonetheless completed 28 minimally invasive pancreaticoduodenectomies (12 RAPD and 16 HLAPD) during the study period. What has evolved over time, however, is our willingness and con�-dence to begin a procedure by laparoscopy and then convert to hybrid or open if needed, so that the patient may bene�t from as much of a minimally invasive procedure as possible. We have noted no deaths or signi�cant differences in major com-plications and thus plan to pursue RAPD at our institution in all patients amenable to a minimally invasive approach accord-ing to our aforementioned inclusion criteria.

CONCLUSION

In our early experience, RAPD is safe and feasible and can ensure adequate oncologic resections and lymphadenectomies with acceptable complication rates compared with HLAPD. The importance of minimal blood loss, lower levels of post-operative opioids and shorter LOS emphasize the ability to perform robotic reconstructions safely in a highly specialized centre with previous experience in laparoscopic pancreatic resections. Our initial results with RAPD are positive and encouraging compared with both HLAPD and an open pro-cedure, further providing evidence that the robotic platform provides meaningful patient bene�t and should be considered in centres with access to a robot and trained surgeons.

Af�liations: From the Department of Surgery, Sir Mortimer B. DavisJewish General Hospital, McGill University, Montreal, Que. (Piedimonte,Wang, Bergman, Vanounou); and the Lady Davis Institute for MedicalResearch, Montreal, Que. (Bergman).


Contributors: S. Piedimonte, S. Bergman and T. Vanounou designed the study. S. Piedimonte and Y. Wang acquired and analyzed the data, which T. Vanounou also analyzed. S. Piedimonte and T. Vanounou wrote the article, which all authors reviewed and approved for publication.

References

1. Giulianotti PC, Sbrana F, Bianco FM, et al. Robot-assisted laparoscopic pancreatic surgery: single-surgeon experience. Surg Endosc 2010;24:1646-57.

2. Ejaz A, Sachs T, He J, et al. A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the Nationwide Inpatient Sample. Surgery 2014;156:538-47.

3. Correa-Gallego C, Dinkelspiel HE, Sulimanoff I, et al. Minimally-invasive vs open pancreaticoduodenectomy: systematic review and meta-analysis. J Am Coll Surg 2014;218:129-39.

4. Lei P, Wei B, Guo W, et al. Minimally invasive surgical approach compared with open pancreaticoduodenectomy: a systematic review and meta-analysis on the feasibility and safety. Surg Laparosc Endosc Percutan Tech 2014;24:296-305.

5. Giulianotti PC, Coratti A, Angelini M, et al. Robotics in general surgery: personal experience in a large community hospital. Arch surg 2003;138:777-84.

6. Zureikat AH, Hogg ME, Zeh HJ III. The utility of the robot in pan-creatic resections. Adv Surg 2014;48:77-95.

7. Wang Y, Bergman S, Piedimonte S, Vanounou T. Bridging the gap between open and minimally invasive pancreaticoduodenectomy: the hybrid approach. Can J Surg 57:263-70.

8. DeOliveira ML, Winter JM, Schafer M, et al. Assessment of complica-tions after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006;244:931-7, discussion 7-9.

9. Bassi C, Dervenis C, Butturini G, et al. Postoperative pancreatic �stula: an international study group (ISGPF) de�nition. Surgery 2005;138:8-13.

10. Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested de�nition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761-8.

11. Kleespies A, Rentsch M, Seeliger H, et al. Blumgart anastomosis for pancreaticojejunostomy minimizes severe complications after pancre-atic head resection. Br J Surg 2009;96:741-50.

12. Narula VK, Mikami DJ, Melvin WS. Robotic and laparoscopic pan-creaticoduodenectomy: a hybrid approach. Pancreas 2010;39:160-4.

13. Horiguchi A, Uyama I, Miyakawa S. Robot-assisted laparoscopic pan-creaticoduodenectomy. J Hepatobiliary Pancreat Sci 2011;18:287-91.

14. Zeh HJ, Zureikat AH, Secrest A, et al. Outcomes after robot-assisted pancreaticoduodenectomy for periampullary lesions. Ann Surg Oncol 2012;19:864-70.

15. Zureikat AH, Breaux JA, Steel JL, et al. Can laparoscopic pancreaticodu-odenectomy be safely implemented? J Gastrointest Surg 2011;15:1151-7.

16. Chalikonda S, Aguilar-Saavedra JR, Walsh RM. Laparoscopic robotic-assisted pancreaticoduodenectomy: a case-matched comparison with open resection. Surg Endosc 2012;26:2397-402.

17. Zhou NX, Chen JZ, Liu Q, et al. Outcomes of pancreatoduodenectomy with robotic surgery versus open surgery. Int J Med Robot 2011;7:131-7.

18. Zureikat AH, Nguyen KT, Bartlett DL, Zeh HJ, Moser AJ. Robotic-assisted major pancreatic resection and reconstruction. Arch Surg 2011;146:256-61.

19. Nigri G, Petrucciani N, La Torre M, et al. Duodenopancreatectomy: open or minimally invasive approach? Surgeon 2014;12:227-34.




Functional outcomes of acutely infected knee arthroplasty: a comparison of different surgical treatment options

Background: An infected total knee arthroplasty (TKA) can be treated with irrigation and débridement with polyethylene exchange (IDPE) or a 2-staged revision (2SR). Although research has examined infection eradication rates of both treatments, patient outcomes have not been reported. We examined patient-reported outcomes following treatment compared with matched, noninfected controls.Methods: We retrospectively identi�ed patients with infected TKAs who had undergone the index procedure between May 1991 and November 2011. Patient-reported outcomes included the 12-item Short Form Health Survey, Western Ontario and McMaster Uni-versities Arthritis Index, and Knee Society Scores as well as range of motion. Patients with noninfected primary TKAs matched by age and age-adjusted Charlson Comorbidity Index score were used as controls. Intention-to-treat groups of 2SR and IDPE were used, with the IDPE group subdivided into successful and unsuccessful groups.Results: We included 145 patients with infected TKAs with mean follow-up of 64.2 months and 145 controls with a mean follow-up of 35.4 months in our analysis. Out-comes of the controls and the successful IDPE groups were equivalent. The 2SR cohort had lower scores in all categories than controls. There was a 39% success rate in eradicat-ing infection with IDPE. Patients in whom IDPE failed had lower scores in all categories than controls. There was no difference between the failed IDPE group and the 2SR group.Conclusion: Controversy regarding treatment options for acutely infected TKA has been focused on infection eradication. However, functional outcomes following treat-ment need to be taken into consideration. Patients whose infections were successfully treated with IDPE had equivalent outcomes to controls.

Contexte : Il est possible de traiter une arthroplastie totale du genou (ATG) infectée par irrigation et débridement avec changement du polyéthylène (IDCP) ou par une révision en 2 étapes. Même si la recherche a examiné les taux d’éradication de l’infection au moyen des 2 traitements, les résultats chez les patients n’ont pas fait l’objet de rapports. Nous avons comparé les résultats enregistrés chez les patients traités à ceux de témoins assortis non infectés. Méthodes : Nous avons recensé de manière rétrospective les patients qui ont présenté une infection de leur ATG et qui avaient initialement subi leur intervention entre mai 1991 et novembre 2011. Les résultats rapportés par les patients incluaient le questionnaire SF (Short Form) sur la santé en 12 points, l’indice WOMAC (établi par les universités Western Ontario et McMaster), le score de la Knee Society, de même que l’amplitude de mouvement. Des patients soumis à une ATG primaire non infectée assortis selon l’âge et le score de comorbidités de Charlson ajusté selon l’âge ont servi de participants témoins. On a réparti les groupes selon l’intention de traiter par révision en 2 étapes ou par IDCP; le groupe IDCP a été subdivisé selon que l’intervention avait réussi ou non. Résultats : Notre analyse a regroupé 145 patients dont l’ATG s’était infectée et qui ont été suivis en moyenne pendant 64,2 mois, et 145 témoins suivis en moyenne pendant 35,4 mois. Les résultats ont été équivalents chez les témoins et les groupes dont l’IDCP avait réussi. La cohorte soumise à la révision en 2 étapes a obtenu des scores moindres dans toutes les catégories, comparativement aux témoins. On a noté un taux de succès de 39 % pour l’éradication de l’infection avec l’IDCP. Les patients chez qui l’IDCP a échoué présentaient des scores moindres dans toutes les catégories comparativement aux témoins. On n’a noté aucune différence entre le groupe chez qui l’IDCP avait échoué et le groupe soumis à la révision en 2 étapes. Conclusion : La controverse quant aux options thérapeutiques pour les infections aiguës d’ATG portait sur l’éradication de l’infection. Or, les résultats fonctionnels après le traite-ment devraient aussi entrer en ligne de compte. Chez les patients dont les infections ont été traitées avec succès par IDCP, les résultats ont été équivalents à ceux des témoins.

Ivan Dzaja, MD James Howard, MD, MSc Lyndsay Somerville, PhD Brent Lanting, MD

Accepted for publication Jul. 2, 2015

Correspondence to: I. Dzaja Department of Surgery London Health Sciences Centre London ON N6A 5W9 [email protected]

DOI: 10.1503/cjs.017614

acute-dzaja.indd 402 2015-11-10 9:53 AM


RESEARCH

P eriprosthetic joint infection is a devastating compli-cation after total knee arthroplasty (TKA). Between 2005 and 2006, 25% of revisions were to manage

infection.1 Demand for primary TKA in the United States is projected to grow by 673% to 3.48 million procedures by 2030.2 This would translate into a huge number of patients experiencing periprosthetic joint infections, with the care of these patients representing a substantial �nan-cial burden to society. The surgical options for treatment of periprosthetic infection include irrigation and débride-ment with polyethylene exchange (IDPE), single-stage revision, or 2-stage revision (2SR).

Irrigation and débridement with polyethylene exchange is an attractive alternative for both patient and surgeon. Compared with a 2SR, bene�ts of an IDPE include reten-tion of implants, preservation of bone stock, shorter pro-cedure duration, less chance of intraoperative fracture from removal of components and implantation of cement spacers, and faster postoperative rehabilitation.3–5 How-ever, the reported success rate of IDPE is variable, with reports ranging from 29% to 83%.6–10 By comparison, 2SR is considered the gold standard, with success rates reported in the range of 75%–100%.11–17 In addition, it has been reported that failure rates of 2SR for TKA infec-tions are higher in patients treated with previous IDPE than in patients who did not receive IDPE.18 Therefore, surgeons considering IDPE need to balance potential bene�ts of the procedure with the lower eradication rate and potentially decreased chance of eradication should the patient ultimately receive 2SR.

There may be a role for IDPE in certain situations, such as the treatment of acute postoperative and acute hemato-genous infections.19 An acute postoperative infection has been de�ned as one that occurs within the �rst 4 weeks after index TKA.20 Other studies are more reserved in their rec-ommendations and state that IDPE should be consider ed only in immunologically optimized patients with acute non-Staphylococcal infections.21 Although there is an abundance of literature studying the successful eradication rates with IDPE and 2SR, there is a paucity of data reporting on the patient experience or patient satisfaction associated with these revision procedures. Understanding patient-reported satisfaction is important to the treatment decision process. Therefore, the purpose of this study was to examine patient-reported outcomes in patients with infected TKAs based on whether the patients were treated with initial 2SR, successful IDPE, or failed IDPE with subsequent 2SR; to compare each of the above cohorts to a matched control group of patients with noninfected TKAs; and to determine the suc-cess rates of 2SR and IDPE in our study population.

METHODS

After obtaining institutional review board approval, we performed a database query to identify patients whose

index TKAs, performed between May 1991 and Novem-ber 2011, were acutely infected. Inclusion criteria for our retrospective review were a minimum 1-year follow-up after surgical treatment of infection.

All procedures were performed by 1 of 7 surgeons at our institution. All 7 are high-volume, arthroplasty fellowship–trained surgeons. Implant type for the index procedures included varying levels of constraint, includ-ing posterior stabilized, varus-valgus constrained non-hinged, and hinged knees.

In 2011, The Musculoskeletal Infection Society created guidelines for the diagnosis of periprosthetic joint infection (PJI). A de�nite diagnosis of PJI can be made when the fol-lowing conditions are met.22

• Sinus tract communicating with the prosthesis.• Pathogen isolated by culture from 2 separate tis-

sue or �uid samples obtained from the affected prosthetic joint.

• Presence of at least 4 of the following: elevated serum erythrocyte sedimentation rate (ESR) or serum C-reactive protein (CRP) concentration, elevated synovial white blood cell count, elevated synovial neutrophil percentage, presence of puru-lence in the affected joint, isolation of a micro-organism in 1 culture of periprosthetic tissue or fluid, and more than 5 neutrophils per high-power �eld in 5 high-power �elds observed from histologic analysis of periprosthetic tissue at ×400 magni�cation.

At our institution, diagnosis of infection follows these criteria, with the whole clinical picture used to guide treatment. Threshold values for ESR and CRP in the present study were are 30 mm/hr and 10 mg/L, respect-ively. We excluded patients with less than 1 year of com-plete follow-up.

Identi�ed patients were matched to a control cohort of patients with noninfected primary TKAs based on age and the age-adjusted Charlson Comorbidity Index (CCI) score. The CCI score is a validated method of estimating risk of death from comorbid disease and has also been found to correlate well with major complica-tions in revision surgery.23,24 Patients with a surgically managed infected TKA were then divided into either the 2SR or IDPE group based on intention to treat. The type of treatment performed was at the discretion of the treating surgeon. The IDPE group was then further subdivided based on whether the IDPE was successful or unsuccessful at eradicating infection; patients in whom IDPE was not successful required subsequent 2SR. Both acute hematogenous and acute postoperative infections were defined as those presenting within 4 weeks of onset of symptoms. We considered the infec-tion to be eradicated when the in�ammatory markers had normalized, the clinical symptoms had improved and the surgical wound had healed.



RECHERCHE

Functional outcomes and reoperations associated with unsuccessful eradication of infection were reviewed. We used the most recent patient-reported scores and range of motion (ROM) for analysis. For patients who had unsuccessful IDPE and required subsequent 2SR, clinical outcomes were measured at their most recent follow-up (i.e., after their 2SR). We calculated CCI scores based on a review of patient charts. At each clinic visit, ROM was recorded using a goniometer; ROM at the initial visit and at latest review was used in this study. Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Society Clinical Rating System (KSS) and the 12-item Short-Form Health Survey (SF12) scores were recorded from standardized forms that are routinely used for all arthroplasty patients at our institu-tion. All 3 scores have been validated for use in quantify-ing knee pain and function.25–27


We used the Statistical Package for the Social Sciences (SPSS Inc.) for the statistical analysis. We used the Stu-dent t test for parametric comparisons and the Mann–Whitney U test for nonparametric comparisons between the groups. The Mann–Whitney U test was used when data for a particular variable did not meet the distribution assumptions required by their parametric counterpart.

RESULTS

During our study period, 1857 knee revisions were per-formed at our institution. Review of our database identi-

fied 145 infected TKAs in 145 patients. Of the 145 patients with infected TKAs, 91 were treated initially with 2SR and 54 were treated with IDPE. Of the 91 patients treated with 2SR, 79 had successful eradication of infection and 12 had reoperations for infection. Of the 54 patients treated with IDPE, 21 had successful infection eradication and 33 had a persistent infection and required 2SR (Fig. 1). All of the patients in our cohort in whom IDPE failed received a subsequent 2SR. Of the 21 patients in whom IDPE was successful, 9 had their infections diag-nosed during the acute postoperative period and 12 had diagnoses of acute hematogenous infection. Of the 33 patients in whom IDPE was unsuccessful, 4 had their infections diagnosed during the acute postoperative period and 29 patients had diagnoses of acute hemato-genous infection (Fig. 1). In other words, acute postopera-tive infection in our patient cohort represented 43% of successful IDPE and 12% of failed IDPE.

There was no difference in age, CCI scores or body mass index between controls and patients with infected TKAs (Table 1). Mean clinical follow-up for patients with infected TKAs was 64.2 (range 12–237) months compared with 35.4 (range 24–120) months in the control group (p < 0.001; Table 1).

For the successful IDPE cohort, 6.7% of patients had a hinged prosthesis and 93.3% had posterior stabilized pros-theses. All patients in the failed IDPE group had posterior stabilized prostheses. In the 2SR group, 6.1% had a hinged prosthesis, 57.3% had varus-valgus constrained prostheses, and 36.6% had posterior stabilized prostheses. The mean duration from initial arthroplasty surgery to the 2SR was 31.7 (range 2–180) months. The mean duration from initial

Fig. 1. Distribution of patients based on treatment algorithm. 2SR = 2-staged revision; IDPE = irrigation and débridement with polyethylene exchange.

145 total infected

patients

91 2SR patients

54 IDPE patients

21 successful IDPE patients

33 unsuccessful IDPE patients

9 acute postoperative

infections

12 acute hematogenous

infections

4 acute postoperative

infections

29 acute hematogenous

infections



RESEARCH

arthroplasty to successful IDPE was 15.3 (range 1–89) months. Finally, the mean duration from initial arthroplasty to failed IDPE was 23.8 (range 1–120) months.

Compared with the 2SR group, the control group per-formed better on all measures, with better SF12 mental composite scale (p = 0.005), SF12 physical composite scale (p = 0.002), WOMAC (p < 0.001) and KSS (p < 0.001) scores and improved ROM (p < 0.001) at latest review (Table 2). When the 2SR group was divided into success-ful and failed 2SR, the control group performed better than both on all measured outcomes (all p < 0.05). Simi-larly, the control group performed better on all measures than the failed IDPE group (all p < 0.05; Table 3). Com-paring the failed IDPE group with the 2SR group revealed no difference in any outcome (all p > 0.05; Table 4). Com-paring the control group with the successful IDPE group demonstrated no difference in any measured outcome (all p > 0.05; Table 5). The success rate with IDPE was 39% and the success rate with 2SR was 87% in our cohorts.

DISCUSSION

Periprosthetic joint infection continues to be a challenge in TKA for both patients and surgeons. Twenty-�ce percent of revisions are done as a result of infection,1 with an inci-dence rate of 1% for TKA.28 The optimal treatment for patients with infected TKAs is controversial. While 2SR remains the gold standard in treatment with an eradication rate ranging from 75% to 100%,11–17 there is no clear con-sensus on the role of IDPE in the treatment of peripros-thetic infection. Compared with 2SR, the bene�ts of IDPE include retention of implants with preservation of bone stock, shorter procedure durations, decreased chance of intraoperative fracture from removal of components with implantation of cement spacers, and faster postoperative rehabilitation.3–5 The main arguments against the use of IDPE as a treatment option have centered on its low suc-cess rate at eradicating infection and on the possibility that IDPE may reduce the success rate of a subsequent 2SR.18 There is an abundance of literature on the treatment of an infected TKA with success rates of IDPE reported to range from 29% to 83%.6–10 Therefore, we elected not to focus on success or failure rates of eradication. Instead, the aim of the present study was to add to the body of litera-ture by being, to our knowledge, the �rst study to focus on patient-reported outcomes based on treatment provided.

Our results demonstrate that there is no difference in patient-reported clinical outcomes when comparing

Table 1. Patient demographic and clinical characteristics

Group; mean

Characteristic Control Infection p value

Age, yr 67.7 68.9 0.21

CCI score 1.51 1.65 0.49

BMI 32.8 33.1 0.84

Follow-up, mo 35.4 64.2 < 0.001

BMI = body mass index; CCI = Charlson Comorbidity Index.

Table 2. Outcome scores comparing controls with patients with infected TKAs who received a 2SR

Group; mean

Outcome measure Control 2SR p value

SF12 mental component score 53.4 49.7 0.045

SF12 physical component score 38.9 33.8 0.002

KSS 169.3 135.3 < 0.001

WOMAC 78.1 62.8 < 0.001

ROM, arc 116.9 91.1 < 0.001

2SR = 2-staged revision; KSS = Knee Society score; ROM = range of motion; SF12 = 12-item Short Form Health Survey; TKA = total knee arthroplasty; WOMAC = Western Ontario and McMaster Universities Arthritis Index.

Table 3. Outcome scores comparing controls with patients with infected TKAs in whom IDPE failed

Group; mean

Outcome measure Control Failed IDPE p value

SF12 mental component score 53 46.1 0.026


KSS 170.4 142.1 0.004

WOMAC 76.2 63.9 0.036

ROM, arc 116.6 93.6 0.003

IDPE = irrigation and débridement with polyethylene exchange; KSS = Knee Society score; ROM = range of motion; SF12 = 12-item Short Form Health Survey; TKA = total knee arthroplasty; WOMAC = Western Ontario and McMaster Universities Arthritis Index.

Table 5. Outcomes comparing controls with patients with infected TKAs in whom IDPE was successful

Group; mean

Outcome measure Control Successful IDPE p value



KSS 160.8 150.1 0.48

WOMAC 75.6 72.1 0.67

ROM, arc 109 110.9 0.56

2SR = 2-staged revision; IDPE = irrigation and débridement with polyethylene exchange; KSS = Knee Society score; ROM = range of motion; SF12 = 12-item Short Form Health Survey; TKA = total knee arthroplasty; WOMAC = Western Ontario and McMaster Universities Arthritis Index.

Table 4. Outcome scores comparing failed IDPE with 2SR

Group; mean

Outcome measure Failed IDPE 2SR p value



KSS 141.8 135.3 0.54

WOMAC 63.9 62.8 0.93

ROM, arc 93.4 91.1 0.47

2SR = 2-staged revision; IDPE = irrigation and débridement with polyethylene exchange; KSS = Knee Society score; ROM = range of motion; SF12 = 12-item Short Form Health Survey; TKA = total knee arthroplasty; WOMAC = Western Ontario and McMaster Universities Arthritis Index.



RECHERCHE

unsuccessful IDPE and 2SR. Most interestingly, we found no difference in any outcome when comparing the control group with the successful IDPE group. These �ndings are important when counselling a patient on the treatment options available for an infected TKA. The improved satis-faction of a successful IDPE must be weighed against the lower rates of successful eradication, and these issues need to be discussed with the patient.

In our cohort, IDPE resulted in an eradication rate of 39%, which is consistent with rates reported in the litera-ture.6–10 Similarly, the eradication rate after 2SR in our cohort was 87%, which is also consistent with published rates.11–17 Treatment with IDPE is more likely to be suc-cessful in cases of acute postoperative and acute hemato-genous infections.19 The failed IDPE group in our study had a greater proportion of acute hematogenous infection than the successful IDPE group. It is possibile that some of our patients in whom IPDE failed actually had misdiag-nosed chronic infections. However, the 39% eradication rate in our study is consistent with that reported in previ-ous studies evaluating IDPE for infected TKAs.6–10 Fur-thermore, the main purpose of the present study was to report on outcomes based on the treatment patients received rather than the success or failure of eradication.

Limitations

The study limitations were as follows. First, this study involved a retrospective review and was therefore subject to all the biases associated with this type of study design. Second, some patients in whom IDPE failed had been referred from other hospitals. As the referring surgeons followed IDPE treatment protocols similar to those at our tertiary care centre, these patients were included in the current study to maximize cohort size. Third, it should be noted that there is a difference between the infected and control cohorts with regards to mean duration of follow-up (64.2 mo in the infected cohorts v. 35.4 mo in the con-trol cohort). The control cohort was selected by matching patients with noninfected primary TKAs with patients in the infected cohort based on age and age-adjusted CCI scores. This process resulted in a comparable control cohort in terms of patient number, age, age-adjusted CCI and body mass index. As a result of the matching process, there was a difference in mean duration of follow-up between the cohorts. However, since previous literature has demonstrated that clinical outcome scores do not change signi�cantly beyond 18 months after surgery,29,30 the comparison of clinical outcomes in the cohorts is still relevant despite the differential follow-up. Finally, the data included in the current study depend on the quality of the data recorded in the medical records and are there-fore subject to the limitations faced by many retrospective cohort designs. In some cases the onset of symptoms were not well recorded in terms of hours and/or days. There-

fore, although we could de�nitively identify that patients �t our de�nition of acute symptoms (< 4 wk), in some cases we were unable to reliably calculate an hour or day value for onset of symptoms. As a result we have not pre-sented these data in our study.

The main strength of this study is that it offers a unique look at a large patient cohort experiencing a dif�cult compli-cation after TKA. It also examines how different treatment algorithms affect patient-reported outcomes and ROM after treatment of infection. To our knowledge, patient-reported outcomes have previously not been published in the litera-ture or been considered as part of the controversy regarding the appropriate management of the infected TKA.

CONCLUSION

There may be a role for IDPE in the treatment of peripros-thetic infections owing to the potential for greater patient satisfaction with IDPE than with 2SR. The improved satis-faction associated with a successful IDPE must be weighed against its lower rate of successful eradication of infection. By attempting to identify the patients in whom IDPE is most likely to succeed, a surgeon can maximize patient out-comes when dealing with periprosthetic infection.

Af�liations: From the Department of Orthopaedic Surgery, Western University (Dzaja, Howard, Lanting); and the Department of Ortho-paedic Surgery, London Health Sciences Centre (Howard, Somerville, Lanting), London, Ont.

Competing interests: J. Howard declares consultancy fees from DePuy, Smith and Nephew and Stryker; grants from DePuy; speaker fees from DePuy and Smith and Nephew; and institutional research support from DePuy, Smith and Nephew, Stryker, Zimmer and Micro-port. B. Lanting declares travel assistance from Smith and Nephew. No other competing interests declared.

Contributors: I. Dzaja, J. Howard and B. Lanting designed the study. I. Dzaja, L. Somerville and B. lanting acquired the data, which all authors analyzed. I. Dzaja and L. Somerville wrote the article, which all authors reviewed and approved for publication.

References

1. Bozic KJ, Kurtz SM, Lau EL, et al. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res 2010;468:45-51.

2. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007;89:780-5.

3. Choi HR. Can implant retention be recommended for treatment of infected TKA? Clin Orthop Relat Res 2011;469:961-9.

4. Pulido L. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 2008;466:1710-5.

5. Fisman DN. Clinical effectiveness and cost-effectiveness of 2 man-agement strategies for infected total hip arthroplasty in the elderly. Clin Infect Dis 2001;32:419-30.

6. Rand JA. Alternatives to reimplantation for salvage of the total knee arthroplasty complicated by infection. Instr Course Lect 1993;42:341-7.

7. Mont MA, Waldman B, Banerjee C, et al. Multiple irrigation, debridement, and retention of components in infected total knee arthroplasty. J Arthroplasty 1997;12:426-33.



RESEARCH

8. Silva M, Tharani R, Schmalzried TP. Results of direct exchange or debridement of the infected total knee arthroplasty. Clin Orthop Relat Res 2002;404:125-31.

9. Marculescu CE, Berbari EF, Hanssen AD, et al. Outcome of prosthetic joint infections treated with debridement and retention of components. Clin Infect Dis 2006;42:471-8.

10. Fehring TK, Odum SM, Berend KR, et al. Failure of irrigation and debridement for early postoperative periprosthetic infection. Clin Orthop Relat Res 2013;471:250-7.

11. Hirakawa K, Stulberg BN, Wilde AH, et al. Results of 2-stage reimplan-tation for infected total knee arthroplasty. J Arthroplasty 1998;13:22-8.

12. Wilson MG, Kelley K, Thornhill TS. Infection as a complication of total knee-replacement arthroplasty. J Bone Joint Surg Am 1990;72:878-83.

13. Hofmann AA, Goldberg T, Tanner AM, et al. Treatment of infected total knee arthroplasty using an articulating spacer: 2–12 year experience. Clin Orthop Relat Res 2005;430:125-31.

14. Fehring TK, Odum S, Calton TF, et al. Articulating versus statis spacers in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop Relat Res 2000;380:9-16.

15. Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term follow-up of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat Res 2004;428:35-9.

16. Hart WJ, Jones RS. Two-stage revision of infected total knee replace-ments uring articulating cement spacers and short-term antibiotic therapy. J Bone Joint Surg Br 2006;88:1011-5.

17. Teeny SM, Dorr L, Murata G, et al. Treatment of infected total knee arthroplasty. J Arthroplasty 1990;5:35-9.

18. Sherrell JC, Fehring TK, Odum S, et al. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res 2011;469:18-25.

19. Chiu FY, Chen CM. Surgical debridement and parenteral antibiotics in infected revision total knee arthroplasty. Clin Orthop Relat Res 2007;461:130-5.

20. Segawa H, Tsukayama DT, Kyle RF, et al. Infection after total knee arthroplasty. a retrospective study of the treatment of eighty-one infections. J Bone Joint Surg Am 1999;81:1434-45.

21. Koyonos L, Zmistowski B, Della Valle CJ, et al. Infection control rate of irrigation and debridement for periprosthetic joint infection. Clin Orthop Relat Res 2011;469:3043-8.

22. Parvizi J, Zmistowski B, Zalavras CG. New de�nition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res 2011;469:2992-4.

23. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and vali dation. J Chronic Dis 1987;40:373-83.

24. Koenig K, Huddleston JI 3rd, Huddleston H, et al. Advanced age and comorbidity increase the risk for adverse events after revision total hip arthroplasty. J Arthoplasty 2012;27:1402-7

25. Bellamy N, Buchanan WW, Goldsmith CH, et al. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 1988;15:1833-40.

26. Lingard EA, Katz JN, Wright RJ, et al. Validity and responsiveness of the Knee Society clinical rating system in comparison with the SF-36 and WOMAC. J Bone Joint Surg Am 2001;83-A:1856-64.

27. Resnick B, Nahm ES. Reliability and validity testing of the revised 12-item Short Form Health Survey in older adults. J Nurs Meas 2001;9:151-61.

28. Jämsen E, Varonen M, Huhtala H, et al. Incidence of prosthetic joint infections after primary knee arthroplasty. J Arthroplasty 2010;25:87-92.

29. Fortin PR, Penrod JR, Clarke AE, et al. Timing of total joint replacement affects clinical outcomes among patients with osteoar-thritis of the hip or knee. Arthritis Rheum 2002;46:3327-30.

30. Bachmeier CJ, March LM, Cross MJ, et al. A comparison of out-comes in osteoarthritis patients undergoing total hip and knee replacement surgery. Osteoarthritis Cartilage 2001;9:137-46.

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http://mc.manuscriptcentral.com/cjs




Working toward benchmarks in orthopedic OR ef�ciency for joint replacement surgery in an academic centre

Background: The introduction of 4-joint operating rooms (ORs) to meet provincial wait time targets represented a major change in practice, providing an opportunity to optimize patient care within an OR time allotment of 8 hours. We reviewed our suc-cess rate completing 4 joint replacements within 8 hours and de�ned benchmarks for successful completion.

Methods: We reviewed the surgeries performed in the 4-joint ORs between May and October 2012. Using prospectively collected data from the Surgical Information Management System, each surgery time was divided into the following components: anesthesia preparation time (APT), surgical preparation time (SPT), procedure dura-tion, anesthesia �nishing time (AFT) and turnover time. We de�ned success as 4 joint replacements being completed within the allotted time.

Results: We reviewed 49 4-joint OR days for a total of 196 joint surgeries. Of the 49 days, 24 (49%) were successful. Only 2 surgeons had a success rate greater than 50%. Signi�cant predictors of success were APT (odds ratio 1.09, 95% con�dence interval [CI] 1.02–1.16), procedure duration (odds ratio 1.02, 95% CI 1.00–1.05) and AFT (odds ratio 1.19, 95% CI 1.06–1.34). We calculated probabilities for each component and derived benchmark times corresponding to the probability of 0.60. These benchmarks were APT of 9 min, SPT of 14 min, procedure duration of 68 min, AFT of 4 min and turnover of 15 min.

Conclusion: We established benchmark times for the successful completion of 4 primary joint replacements within an 8-hour shift. Targeted interventions could maximize OR ef�ciency and enhance multidisciplinary care delivery.

Contexte : A�n d’atteindre les cibles provinciales en matière de temps d’attente, on a mis en service des blocs opératoires (BO) dédiés à la réalisation de 4 arthroplasties consécutives. Cette mesure a représenté un changement de pratique majeur et a offert une occasion d’optimiser les soins aux patients à l’intérieur du temps opératoire alloué, soit 8 heures. Nous avons examiné notre taux de succès à effectuer 4 arthro-plasties en 8 heures et dé�ni les critères de réussite.

Méthodes : Nous avons passé en revue les chirurgies effectuées dans les BO dédiés entre mai et octobre 2012. À l’aide des données prospectives fournies par le système de gestion des données chirurgicales, la durée de chaque intervention a été divisée en 5 temps : temps de préparation de l’anesthésie (TPA), temps de préparation chirurgi-cale (TPC), durée de l’intervention, temps de �nalisation de l’anesthésie (TFA) et temps de roulement. La réussite était définie comme la réalisation complète de 4 arthroplasties à l’intérieur des temps alloués.

Résultats : Nous avons analysé 49 jours de BO dédiés, totalisant 196 chirurgies articu-laires. Sur les 49 jours, 24 (49 %) ont été couronnés de succès. Seulement 2 chirurgiens ont obtenu un taux de réussite supérieur à 50 %. Les principaux prédicteurs de succès étaient le TPA (rapport des cotes 1,09, intervalle de con�ance [IC] de 95 % 1,02–1,16), la durée de l’intervention (rapport des cotes 1,02, IC de 95 % 1,00–1,05) et le TFA (rap-port des cotes 1,19, IC de 95 % 1,06–1,34). Nous avons calculé les probabilités pour chaque composante et inféré les critères de durée correspondant à la probabilité de 0,60. Les critères ont été dé�nis comme suit : TPA 9 minutes, TPC 14 minutes, durée de l’intervention 68 minutes, TFA 4 minutes et roulement 15 minutes.

Conclusion : Nous avons établi des durées cibles pour chacune des étapes menant à la réalisation complète de 4 arthroplasties primaires à l’intérieur d’un quart de travail de 8 heures. L’application des cibles aux interventions pourraient maximiser l’ef�cience des BO et améliorer la prestation des soins multidisciplinaires.

Paule E. Beaulé, MD Aaron A. Frombach, MD Jae-Jin Ryu, PhD

Accepted for publication Jul. 14, 2015

Correspondence to: P. Beaulé Division of Orthopaedic Surgery University of Ottawa The Ottawa Hospital 501 Smyth Rd, CCW 1640 Ottawa ON K1H 8L6 [email protected]

DOI: 10.1503/cjs.001215

bench-beaule.indd 408 2015-11-10 10:34 AM

RESEARCH


T here is no doubt that joint replacement surgery improves the quality of life of patients with arth-ritis.1 In recent years, research has focused on regis-

try data to determine trends in patient pro�les and to form a quality control process for assessing the success rate of various implant designs. In addition, institution and gov-ernment agencies are paying closer attention to readmis-sion rates, rates of super�cial wound infection and overall quality of care delivery within that context.2 Overall ef�-ciency is also being examined by these multiple stakehold-ers. This is particularly relevant in a single payer system like Canada’s, in which public funds are the sole source of �nancing and increasing demand is coupled with increas-ing government de�cits. Capacity to increase delivery of joint replacements must be accomplished without increas-ing costs. In 2005, based on the National Health Services initiative, the Canadian government mandated through the National Wait Times Initiative (NWTI) that patients receive their hip or knee replacement within 6 months of the decision for surgery.3 The most recent data from the Canadian Institute of Health Information (CIHI)4 show there is still considerable room for improvement, with most provinces being under the 90% goal despite funding directed speci�cally to decrease wait lists (Fig. 1).4

Various models with set benchmarks (e.g., centralized intake clinics that separate wait times into multiple com-ponents: time to consult, time to surgical decision and �nally time to surgery) have been introduced to improve access to joint replacement care.5 In addition, how to best

improve operating room (OR) ef�ciency has been a subject of much interest in order to meet the increasing demand for joint replacement putting a substantial burden on the hospital system owing to limited resources. Although sev-eral groups have looked at OR inef�ciencies, such as turn-around time and dedicated teams,6,7 there is still a lack of established benchmarks to successfully maximize OR ef�-ciency without increasing resources.8,9

In 2004, a 4-joint OR initiative was instituted within our hospital to minimize wait times for joint replacements by improving overall throughput while minimizing the need to increase the number of OR days to perform joint replacement surgery. As part of this initiative, team lead-ers, customized joint instrument trays and patient selec-tion parameters (i.e., body mass index [BMI] < 35, Ameri-can Society of Anaesthesiologists [ASA] score of 2 or less, no prior joint surgery) were established. The purpose of the present study was to look at the overall success of our high-volume ORs for performing primary joint replace-ments and to de�ne the factors that are associated with successful completion of 4-joint OR cases within a stan-dard 8-hour shift.

METHODS

Four-joint OR data from May 1 to Oct. 31, 2012, were analyzed retrospectively for surgical times. We obtained approval from our institutional ethics committee before the study began.

Fig. 1. Lower-extremity arthroplasties by Canadian province, 182-day success rate. PEI = Prince Edward Island.

0.65

0.72

0.66

0.58

0.85

0.78

0.6

0.43

0.61

0.93

0.76

0.8

0.77

0.68

0.89

0.81

0.69

0.58

0.8

0.92

British Columbia

Alberta

Saskatchewan

Manitoba

Ontario

Quebec

New Brunswick

Nova Scotia

PEI

Newfoundland

Hip replacements Knee replacements


RECHERCHE


The goal of the 4-joint room initiative was to complete the cases within a standard 8 hour shift (i.e., 7:30 am to 3:30 pm). All joint replacements were completed by 5 arthroplasty surgeons and 27 different anesthesiologists. Spinal and general anesthetic are both commonly used for lower extremity reconstruction, and the anesthesiologist decided on the method of anesthesia in consultation with the patient. Our institution does not have a block room and, as such, all spinal anesthetics were administered after the patient entered the operating theatre. All surgical time data were prospectively entered using the Surgical Infor-mation Management Systems (SIMS). The surgical time intervals were de�ned using the following events as out-lined by the American Association of Clinical Directors, with modi�cations noted by asterix: anesthesia preparation time (APT; patient in room* to anesthesia ready), surgical preparation time (SPT; anesthesia ready to procedure start), procedure duration (procedure start time to pro-cedure �nish), anesthesia �nish time (AFT; procedure �n-ish to patient out of room*), and turnover time (room cleanup start to patient in room).10 The APT immediately follows turnover time during the day, as a smooth transi-tion into the room is expected once the room is ready.


We report basic descriptive statistics (mean, median, stan-dard deviation and range) as appropriate. For the analysis of surgical time components, we used t tests to compare surgical intervals on successful and unsucessful days. Suc-cess was de�ned as the last patient (fourth case) of the day leaving the operating theatre within the allotted 8-hour shift. We performed logistic regression analysis to deter-mine significant predictors for success of 4-joint ORs. Furthermore, we used the following equation to calculate predicted probabilities (p) for each time component, aver-aged per day: p = e ^ (a + bTime)/(1 + e ^ (a + bTime)).

RESULTS

During the study period, 196 joint replacements were completed in 49 4-joint OR days: 80 (40.8%) total hip arthroplasties (THA), 55 (28%) total knee arthroplasties (TKA), 38 (19.4%) hip resurfacing (HR) and 23 (11.7%) unicompartmental knee arthroplasties (UKA). The mean age of patients was 62 (range 25–87) years; 85 patients were men and 111 were women (Table 1). The mean BMI was 29.6 (range 20.5–48.3), and the median ASA score was 2 (range 1–3). Twenty-four patients received a general anesthetic, and 164 had a spinal anesthetic. There were 8 cases of converted spinal to general anesthetics.

The overall success rate for completion of 4-joint OR days within the allotted time was 49% and varied from 0% to 80% among surgeons. The mean procedure duration for all procedures was 70 (range 33–113) min (Table 2).

Each surgical time interval is reported in Table 3, with mean, maximum and minimum values. The mean pro-cedure duration for days that were successful versus unsuc-cessful were 68.6 ± 13.2 and 72.2 ± 12.4 min, respectively (95% con�dence interval [CI] –7.2 to –0.01, p = 0.05). Pro-cedures were slightly shorter on successful days for 3 of the 4 surgeons (surgeons A, C and D) who had more than 1 successful day, although this difference for each surgeon was not signi�cant (Table 4).

Each temporal component was averaged per day, and we used logistic regression to calculate predicted

Table 1. Patient demographic and clinical characteristics

Characteristic No. (%) or mean (range)

Sex

Male 85 (43%)

Female 111 (57%)

BMI 29.6 (20.5–48.3)

Age, yr 62 (25–87)

ASA score 2.4 (1–3)

ASA = American Society of Anaesthesiologists; BMI = body mass index.

Table 2. Procedure duration, by procedure and surgeon

Procedure/surgeon Mean (range), min

Knee hemiarthroplasty 68 (44–88)

Hip resurfacing 69 (52–87)

Total hip arthroplasty 73 (33–107)

Total knee arthroplasty 68 (46–113)

Surgeon A 71.3 (51–104)

Surgeon B 73.3 (57–90)

Surgeon C 71.7 (53–107)

Surgeon D 66.5 (33–83)

Surgeon E 69.9 (44–113)

Table 3. Interval durations

Interval Mean (range), min

Anesthesia preparation time 12 (5–32)

Anesthesia �nishing time 5 (0–19)

Surgical preparation time 16 (4–26)

Procedure duration 70 (33–113)

Turnover time 19 (8–48)

Table 4. Procedure durations for successful and unsuccessful days by surgeons

Success rate, %

Group; mean ± SD

Surgeon Successful Unsuccessful p value

All 49 68.6 (13.2) 72.2 (12.4) 0.05

A 54 68.9 (12.1) 74.1 (12.0) 0.13

B 0 NA 73.3 (9.7) NA

C 50 70.8 (12.6) 72.6 (13.6) 0.64

D 80 66.6 (10.2) 66.3 (10.1) 0.93

E 38 68. 9 (22.1) 70.6 (15.1) 0.81

NA = not applicable; SD = standard deviation.


RESEARCH


probability of success (Table 5 and Table 6). The maxi-mum probabilities of success for the temporal com-ponents ranged from 0.6 to 0.902. Owing to this vari-ability, approximate times that corresponded to the predicted probability of 0.60 were arbitrarily chosen as benchmark estimates. Five anesthesiologists met the average APT benchmark of 9 min, with the range for daily averages spanning 7–20 min. Reaching the bench-mark was common, with 32% of cases having an APT of less than 9 min; however, daily averages were much more dif�cult for the various physicians to achieve. Five of 27 anesthesiologists were able to meet the AFT target of 4 min, with the range of daily averages spanning 2.5–7.8 min. Individual results are shown in Figure 2.

In order to determine factors that contribute to success, we performed a logistic regression analysis with various surgical (procedure type, surgeon, anesthesiologists) and temporal components. Only the following temporal com-ponents emerged as signi�cant predictors of success: APT (odds ratio 0.92, 95% CI 0.86–0.98), procedure duration (odds ratio 0.98, 95% CI 0.95–1.00) and AFT (odds ratio 0.84, 95% CI 0.74–0.94).

DISCUSSION

The demands on the Canadian health care system to do more and better with less are growing, and although some may say that there is no more capacity within our system, there are health care organizations that are succeeding. One model that has been applied with success is that of Lean, which originates from the automotive industry.11 In addition, not only did we �nd that variability in both sur-geon and anesthesiologist had a signi�cant impact on suc-cessful completion, we were also able to delineate other steps (i.e., SPT and AFT) affecting OR ef�ciency.

Ef�ciency in the OR is not only increasing case volume, but also using the same or fewer resources. Given the �xed nature of resources and the inability to expand owing to budget and physical plant restrictions, increasing ef�ciency is paramount to survival in the modern health care envi-ronment. Our study provides a guide for ef�cient utiliza-tion of resources within a standard OR shift to increase throughput of primary arthroplasty cases without increas-ing the budgetary demands by using overtime, extra per-sonnel or added resources, such as block rooms. While other strategies, such as block rooms, have been shown to increase the volume of operations, their role in increasing ef�ciency is less clear.5 More importantly, the increased ef�ciency requires buy-in from all team members, includ-ing the anesthesiology team (e.g., the anesthesiologist will often meet the patient outside the OR during turnover time, allowing a smooth transition into APT from turn-over time).

In addition, the benchmarks we developed and the methods we used to determine them can be spread to other specialties, such as bariatric and thoracic surgery, where a step-wise procedure is carried out with high- volume and predictable pre-, intra- and postoperative pro-cesses in a given setting. More importantly, the predictors of success were examined as individual markers, so if all 4 successful benchmarks (APT of 9 min × 4, SPT of 11 min × 4; procedure duration of 66 min × 4; AFT of 4 min × 4; turnaround time of 15 min × 3) were combined, the 4-joint OR day would be completed in 6.75 hours, leaving room for unpredictable delays, such as a dif�cult induction and/or surgical exposures as well as teaching. By knowing where the workday is against the benchmarks, the surgeon can allocate various responsibilities to resi-dents/fellows and predictably know that the day will �nish

Table 5. Maximum surgical interval times that correspond to 60% success rate (benchmark) and their odds for predicting success

Interval Benchmark, min OR (95% CI) p value

APT 9 1.09 (1.02–1.16) 0.009

SPT 14 1.05 (0.97–1.14) 0.23

Procedure duration 68 1.02 (1.00–1.05) 0.05

AFT 4 1.19 (1.06–1.34) 0.003

Turnover time 15 1.12 (1.05–1.18) < 0.001

AFT = anesthesia �nishing time; APT = anesthesia preparation time; CI = con�dence interval; OR = odds ratio; SPT = surgical preparation time.

Table 6. Comparison between successful and unsuccessful days

Group; mean (range)*

Factor Successful Unsuccessful

No. of patients 96 100

Anesthetic, no. (%)

Spinal 83 (86) 81 (81)

General 13 (14) 19 (19)

Age, yr 61.3 (25–86) 62.6 (35–87)

APT, min 11.4 (5–28) 13.3 (5–32)

APT, % < benchmark 36% 28%

ASA score 2.4 (1–3) 2.3 (1–3)

BMI 29.9 (20.6–44.4) 29.3 (20.5–48.3)

First PIR time, min 7:53 (7:44–8:04) 7:55 (7:42–8:05)

Procedure duration, min

HR 66.9 (56–77) 72.1 (52–87)

THA 71.3 (33–103) 76.1 (45–107)

TKA 67.3 (46–113) 68.7 (47–90)

UKA 62.3 (44–83) 71.2 (50–88)

Procedure prevalence, %

HR 23% 16%

THA 47% 35%

TKA 21% 35%

UKA 9% 14%

Sex, no. (%)

Male 36 (38) 49 (49)

Female 60 (62) 51 (51)

APT = anesthesia preparation time; ASA = American Society of Anesthesiologists; BMI = body mass index; HR = hip resurfacing; PIR = patient in room; THA = total hip arthroplasty; TKA = total knee arthroplasty; UKA = unicompartmental knee arthroplasty. *Unless indicated otherwise.


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on time. More importantly, one can better integrate addi-tional resources (e.g., block rooms, possibly a �fth case) to maximize ef�ciency.

The pool of patients eligible for a joint replacement is not a perfectly homogeneous population, but some trends are present. We initially intended to include only patients with an ASA score of 2 or less and a BMI of 35 or less to allow for successful completion of our 4-joint OR days; however, this was not an attainable booking strategy as too high a percentage of arthroplasty patients were excluded by these restrictions. Whenever possible, these physical parameters were maintained; however, the incidence of increased BMI and ASA score was not signi�cantly differ-ent between successful and unsuccessful days in the data analyzed for the present study.

Limitations

One of the limitations of our study is that the recording of the data within the SIMS system was done by different individuals, potentially introducing variability in the accu-rate assessment of the different time points. Having said that, the data were collected in the same fashion for all cases, consequently minimizing the possible bias in data gathering. More importantly, all members of the OR team were unaware that these data would be later analyzed, making our analysis a real-life assessment and preventing a Hawthorne effect. Another limitation of our study is the

lack of specialized teams (i.e., anesthesiologists), making unclear the potential impact of a specialized team on the various benchmarks. However, because of this lack of spe-cialized teams, our �ndings are likely more applicable to a wider community of surgeons across the country. Hospi-tals that already have specialized anesthesiology and nurs-ing teams may be able to more ef�ciently implement our benchmarks to ensure successful completion of their lists, whereas community hospitals in which human resources are more limited may be able to work toward specialized teams to make their resources go further. Within that context, it is unknown whether a minimum number of joint replacements is required or desired to institute high- efficiency joint replacement ORs. Finally, the level of success was set relatively low at 60%; most individuals and institutions would set higher targets for success at 80%–90%. The low level of success in our study is because of the relatively small number of cases with an associated high variability for the different time points. Having said that, with both groups (successful v. unsuc-cessful 4-joint ORs) being comparable in regards to pro-cedure type, BMI and sex, this certainly permitted us to focus on the surgical work�ow, making our �ndings appli-cable to most institutions.

Interestingly when looking at the impact of procedure duration, surgeon D’s average duration did not differ between successful and unsuccessful days, highlighting the importance of the team and other time points, such

Fig. 2. Breakdown of average anesthesia preparation time (APT) and anesthesia �nishing time (AFT) by anesthesiologist with number of cases completed in a 4-joint operating room during the study period in brackets beside the identi�er.

0

5

10

15

20

A(5) B(4) C(8) D(4) E(20) F(8) G(4) H(8) I(8) J(7) K(4) L(7) M(4) N(12) O(9) P(2) Q(4) R(4) S(12) T(8) U(12) V(4) W(7) X(8) Y(4) Z(4) AA(7)

AFT APT

Anesthesiologist

Tim

e, m

in


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as AFT, for the completion of the 4 cases within an 8-hour timeframe. All too often, the surgeon scrubs out once the wound is closed and goes on to complete other administrative tasks, which may give the impression that the “case” is finished and everyone can take a break. Because the SIMS software did not capture the time of departure of the surgeon, we cannot analyze the impact of the surgeon leaving the OR before the patient on overall room ef�ciency, but this is a possible next step for analysis. As our study has shown, completing this task of exiting the room in an ef�cient and coordinated man-ner is as critical as other key aspects of surgical work-�ow. Similarly the importance of specialized teams is highlighted by the large variability in APT with the 27 anesthesiologists, which contrasts relative grouping of the mean procedure durations within our surgeon group (Table 6). Because the number of arthroplasties to be done per year is capped, it is unlikely that a suf�cient number of cases would be available for all 27 anesthesiol-ogists to reach the pro�ciency required. More import-antly, the bene�ts of an integrated team approach as well as the capacity to provide interprofessional feedback and sustaining the gains in ef�ciency are lost. The bene�ts of dedicated teams of highly specialized individuals who share a common goal in improving ef�ciency in ORs, including academic joint replacement rooms, are well known6,7 and, in turn, permit the maximization of other work�ow ef�ciency measures, such as block/ induction rooms, which despite requiring increases in physical resources may permit a greater number of cases to be performed and the patient selection criteria to be ex pand ed (e.g., higher BMI).

CONCLUSION

Joint replacement programs are the cause of a large part of both a hospital’s expenditures and revenue.9 By break-ing down the delivery of this service in a stepwise fash-ion, we were able to identify predictive measures to allow the successful completion of 4 primary joint replacements in a standard 8-hour OR day. These

benchmarks can facilitate targeted group interventions to improve efficiency and provide direct feedback in regards to individual performances. More importantly, the presence of dedicated teams will ensure the sustain-ability of these efforts.

Acknowledgements: The authors thank Dr. Tim Ramsay at the Ottawa Hospital Research Institute Methods Centre for his statistical advice, Ms. Suham Alexander for providing SIMS data and Mrs. Paula Doering for administrative support at The Ottawa Hospital.

Affiliations: All authors are from the Orthopedic Department, the Ottawa Hospital, Ottawa, Ont.


Contributors: P. Beaulé designed the study. A. Frombach acquired and analyzed the data, which JJ Ryu also analyzed. A. Frombach wrote the article, which all authors reviewed and approved for publication.

References 1. Learmonth ID, Young C, Rorabeck C. The operation of the century:

total hip replacement. Lancet 2007;370:1508-19. 2. ACS National Surgical Quality Improvement Program. American

College of Surgeons. Available: www.hc-sc.gc.ca/hcs-sss/pubs /cha-lcs/2014-cha-lcs-ar-ra/index-eng.php (accessed 2014 Sept. 21).

3. Canada Health Act Annual Report 2013-2014. Health Canada. Avail-able: www.facs.org/quality-programs/acs-nsqip (accessed 2014 Sept. 21).

4. Wait times for priority procedures in Canada, 2013. Canadian Institute for Health Information. Available: https://secure.cihi.ca/estore /productFamily.htm?pf=PFC2065&lang=fr&media=0 (accessed 2014 Sept. 21).

5. Deloitte and Touche LLP. Evaluation of central intake and assess-ment centres for hip and knee replacement: Final Report. Ministry of Health and Long Term Care, 2011.

6. Attarian DE, Wahl JE, Wellman SS, et al. Developing a high- ef�ciency operating room for total joint arthroplasty in an academic setting. Clin Orthop Relat Res 2013;471:1832-6.

7. Small TJ, Gad BV, Klika AK, et al. Dedicated orthopedic operating room unit improves operating room efficiency. J Arthroplasty 2013;28:1066-71.e2.

8. Smith MP, Sandberg WS, Foss J, et al. High-throughput operating room system for joint arthroplasties durably outperforms routine processes. Anesthesiology 2008;109:25-35.

9. Saleh KJ, Novicoff WM, Rion D, et al. Operating-room throughput: strategies for improvement. J Bone Joint Surg Am 2009;91:2028-39.

10. Johnstone R, Garmin JK. Procedural times glossary. Manual for Anesthesia Department Organization and Management 2010. p. 1-23.

11. Fine BA, Golden B, Hannam R, et al. Leading Lean: a Canadian healthcare leader’s guide. Healthc Q 2009;12:32-41.




Is it safe to wait? The effect of surgical wait time on survival in patients with non–small cell lung cancer

Background: The effect of surgical wait times on survival in patients with non–small cell lung cancer (NSCLC) remains largely unknown. Our objective was to determine the effect of surgical wait time on survival and incidence of upstaging in patients with stage I and II NSCLC.

Methods: All patients with clinical stage I and II NSCLC who underwent surgical resection in a single centre between January 2010 and December 2011 were reviewed. Analysis was strati�ed based on preoperative clinical stage. We assessed the effect of wait time on survival using a Cox proportional hazard model with wait time in months as a categorical variable. Incidence of upstaging at least 1 stage was assessed using logistic regression.

Results: We identi�ed 222 patients: 180 were stage I and 42 were stage II. For stage I, wait times up to 4 months had no signi�cant effect on survival or incidence of upstaging. For stage II, patients waiting between 2 and 3 months had signi�-cantly decreased survival (hazard ratio 3.6, p = 0.036) and increased incidence of upstaging (odds ratio 2.0, p = 0.020) than those waiting 0 to 1 month. For those waiting between 1 and 2 months, there was no signi�cant difference in survival or upstaging.

Conclusion: We did not identify an effect of wait time up to 4 months on survival or upstaging for patients with stage I NSCLC. For patients with stage II disease, wait times greater than 2 months adversely affected survival and upstaging.

Contexte : En chirurgie, l’effet des temps d’attente sur la survie des patients atteints d’un cancer du poumon non à petites cellules (CPNPC) demeure pour une bonne part inconnu. Notre objectif était de déterminer l’effet des temps d’attente sur la sur-vie et sur l’incidence de la restadi�cation à un niveau plus élevé chez les patients atteints d’un CPNPC de stade I et II.

Méthodes : Tous les patients présentant un CPNPC clinique de stade I et II ayant subi une résection chirurgicale dans un seul centre entre janvier 2010 et décembre 2011 ont été passés en revue. L’analyse a été strati�ée selon le stade clinique pré-opératoire. Nous avons évalué l’effet des temps d’attente sur la survie à l’aide d’un modèle de risques proportionnels de Cox, les temps d’attente en mois ayant servi de variable catégorielle. L’incidence de la restadi�cation à la hausse d’au moins un stade a été évaluée par régression logistique.

Résultats : Nous avons recensé 222 patients : 180 de stade I et 42 de stade II. Pour le stade I, les temps d’attente allant jusqu’à 4 mois n’ont eu aucun effet signi�catif sur la survie ou sur l’incidence de la restadi�cation. Pour les stades II, les patients ayant attendu de 2 à trois 3 mois ont présenté une réduction signi�cative de la sur-vie (risque relatif 3,6, p = 0,036) et une incidence accrue de restadi�cation (rapport des cotes 2,0, p = 0,02) comparativement à ceux qui avaient attendu 1 mois et moins. Chez les patients ayant attendu 1 ou 2 mois, on n’a noté aucune différence signi�ca-tive sur la survie ou la restadi�cation.

Conclusion : Nous n’avons observé aucun effet d’une attente allant jusqu’à 4 mois sur la survie ou la restadi�cation chez les patients atteints d’un CPNPC de stade I. Pour les patients atteints d’une maladie de stade II, les temps d’attente de plus de 2 mois ont eu un impact négatif sur la survie et la restadi�cation.

Shaun Coughlin, MD Madelaine Plourde, MD Keegan Guidolin, BSc Dalilah Fortin, MD Eric Frechette, MD Richard Malthaner, MD Richard Inculet, MD

Accepted for publication Aug. 28, 2015

Correspondence to: Shaun Coughlin 1963 Beaverbrook Ave London ON N6H5X4 [email protected]

DOI: 10.1503/cjs.007015

lung-coughlin.indd 414 2015-11-10 9:56 AM

RESEARCH


A new diagnosis of lung cancer can be very distress-ing for patients. Adding to this distress is the con-cern that prolonged surgical wait times may result

in cancer progression and impact survival. A study by Visser and colleagues1 identified significantly impaired quality of life in cancer patients awaiting surgical treat-ment. They concluded that surgical wait times should be minimized to optimize patient well-being.

In the province of Ontario, Canada, a wait time tar-get of 28 days has been set for the interval between the decision to operate and resection. This target was man-dated by Cancer Care Ontario and was determined after a literature review2 that identi�ed 57 studies assessing the effect of increased wait times on outcomes across a number of different malignancies, including non–small cell lung cancer (NSCLC). Of the 57 studies identi�ed, 9 were speci�c to lung cancer. These studies generally failed to identify an impact of increased wait times on survival. Cancer Care Ontario concluded that there was very little evidence on the association between surgical wait times and outcomes. In the end, the recommenda-tion of a maximum wait time of 28 days between the decision to operate and the surgical resection re�ects consensus expert opinion.2 We performed a retrospect-ive cohort study to better clarify the effect of increased surgical wait times on survival and the incidence of upstaging in patients with resectable NSCLC.

METHODS

We identi�ed all patients who underwent surgical resec-tion for preoperative clinical stage I or II NSCLC at a single centre between January 2010 and December 2011. Patients were staged according to the seventh edition of the American Joint Committee on Cancer (AJCC) lung cancer staging system. We calculated the surgical wait time as the interval between the decision to operate and the date of surgery. Clinical staging was determined using preoperative computed tomography (CT) of the chest and head as well as positron emission tomography (PET) and invasive mediastinal staging (in the form of mediastinoscopy, endobronchial ultrasonography or endoscopic ultrasonography-guided biospies) when per-formed. Lymph nodes with a standardized uptake value (SUV) of 2.5 or greater were considered positive unless pathological evaluation from preoperative invasive medi-astinal staging showed them to be negative. For patients who did not undergo PET, we considered lymph nodes greater than 1.0 cm in the short axis to be positive unless mediastinal staging proved otherwise.


The primary outcome in this study was survival, which we assessed using a Cox proportional hazard model with

wait time in months as a categorical variable. Using logis-tic regression, we also assessed the secondary outcome of incidence of upstaging. We considered patients to have been upstaged if the pathological stage increased by at least 1 stage compared with the clinical stage. Analysis was strati�ed based on clinical stage based on the hypoth-esis that wait times may affect stage I and II NSCLC dif-ferently. The stage I analysis was adjusted for presence of a complete resection with pathologically negative margins (R0), histology (adenocarcinoma v. nonadenocarcinoma NSCLC) and type of resection (lobar v. sublobar). These potential confounders were selected a priori and were adjusted for in the analysis regardless of statistical signi�-cance. A small sample size precluded any adjustments in the analysis for stage II patients. We considered results to be signi�cant at p < 0.05.

RESULTS

We identi�ed 222 patients who underwent resection for NSCLC during the study period: 180 patients were stage I based on preoperative clinical staging and 42 were stage II.

Stage I

Patient characteristicsOf the clinical stage I patients, 39 had wait times less than 1 month, 79 waited 1 to less than 2 months, 36 waited 2 to less than 3 months, and 26 waited 3 to less than 4 months. No patients had a wait time longer than 4 months. Age and sex were similar among the patients with various wait times (Table 1). There was a trend of decreased tumour size with increased wait times. Adeno-carcinoma was the most frequent histology for tumours in all wait time categories. Most patients underwent lobar resections, with a minority of patients receiving sublobar resections. Most patients received R0 resections (Table 1). All patients underwent CT as part of the sta-ging workup, and 83% of those with clinical stage I NSCLC underwent PET. Only 9% of the stage I patients underwent mediastinal staging. Most prolonged wait times were owing to waits for operating room access. Of the patients waiting longer than 3 months, 5 (19%) were owing to patient request, 1 (4%) was owing to preoperative medical optimization and the remainder (77%) were owing to operating room access.

SurvivalAt total of 32 patients with clinical stage I NSCLC died within a mean follow up of 30 ± 11 months. There was no difference in survival among patients waiting 1 to less than 2 months, 2 to less than 3 months, or more than 3 months compared with those who waited less than 1 month (Table 2). The adjusted survival curves for all 4 wait time groups are displayed in Figure 1. The


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presence of an R0 resection was signi�cantly associated with improved survival (hazard ratio [HR] 4.96, p = 0.013). Neither the type of resection nor the histology of the tumour was signi�cantly associated with survival.

Incidence of upstagingThirty-four (19%) patients with clinical stage I disease were upstaged at least 1 stage. An increase in wait time of up to 4 months was not associated with an increased inci-dence of upstaging (Table 3). There was a trend toward a decreased incidence of upstaging with longer wait times; however, this �nding was not signi�cant. Patients under-going sublobar resection had a decreased incidence of upstaging (odds ratio [OR] 7.82, 95% con�dence interval [CI] 1.00–61.01, p = 0.05). Neither the histology of the tumour nor the presence of an R0 resection was associated with the incidence of upstaging. Fifty-nine percent of upstaged patients had positive N2 lymph nodes on �nal pathology, while 41% had positive N1 nodes. No patients were upstaged based on T stage.

Stage II

Patient characteristicsOf the 42 patients with clinical stage II NSCLC, 16 waited less than 1 month, 19 waited 1–2 months and 7 waited 2 to less than 3 months. No patients waited more than 3 months for surgery. Age was similarly dis-tributed among the wait time groups. There was a slight increase in the proportion of women in the group waiting 1–2 months compared with the other wait time groups (Table 4). Nonadeoncarcinoma was seen more frequently

in those waiting up to 1 month and those waiting 2– 3 months, whereas adenocarcinoma was more common in those waiting 1–2 months (Table 4). Tumour size was similar among the groups, and most patients received R0 resections. One patient who waited 1–2 months had a sublobar resection, whereas all other patients had lobec-tomies or pneumonectomies. All patients underwent CT as part of the staging workup, and 98% of those with clinical stage II NSCLC underwent PET. Thirty-eight percent of patients with stage II disease underwent medi-astinal staging. Most prolonged wait times in patients with stage II disease were owing to waits for operating room access. For patients waiting 2–3 months, 1 (14%) was owing to patient request, 2 (28%) were owing to pre-operative medical optimization and the remainder (57%) were owing to operating room access.

SurvivalA total of 19 patients with clinical stage II NSCLC died within a mean follow up of 26 ± 13 months. Survival did not differ significantly between patients waiting 1–2 months and those waiting up to 1 month (HR 0.925, 95% CI 0.32–2.64, p = 0.89). Those who waited 2–3 months, however, had signi�cantly decreased sur-vival than those waiting up to 1 month (HR 3.6, 95% CI, 1.09–12.09, p = 0.036). Survival curves for the 3 wait time groups are shown in Figure 2.

Incidence of upstagingNine (21%) patients with clinical stage II disease were upstaged at least 1 stage. Patients waiting 1–2 months did not have a significantly increased incidence of

Table 1. Stage I patient (n = 180) characteristics

Wait time group; mean ± SD or no. (%)

Characteristic 0 to < 1 mo 1 to < 2 mo 2 to < 3 mo 3 to < 4 mo

No. of patients 39 79 36 26

Age, yr 69 ± 8.0 68 ± 10 68 ± 10 64 ± 13

Female sex 21 (53) 30 (38) 21 (58) 16 (62)

Tumour size, cm 3.09 ± 1.03 2.74 ± 1.10 2.42 ± 0.94 2.38 ± 0.83

Adenocarcinoma 24 (62) 44 (56) 22 (61) 17 (65)

Sublobar resection 5 (13) 15 (19) 5 (14) 3 (12)

R0 resection 36 (92) 76 (96) 34 (94) 26 (100)


Table 2. Stage I survival analysis

Factor p value Hazard ratio

Wait 0 to < 1 mo — 1.0

Wait 1 to < 2 mo 0.77 0.875

Wait 2 to < 3 mo 0.99 1.007

Wait > 3 mo 0.92 1.064

R0 resection 0.013 4.959 (favours R0 resection)

Sublobar v. lobectomy 0.28 2.228 (favours sublobar)

Histology 0.21 1.262 (favours adenocarcinoma)


RESEARCH


upstaging compared with those who waited less than 1 month (OR 4.0, 95% CI 0.40–40.08, p = 0.24). Those waiting 2–3 months, however, had a significantly increased incidence of upstaging (OR 20.0, 95% CI 1.61–248.3, p = 0.020). Fifty percent of upstaged patients had T3 N1 disease on �nal pathology, while 33% had positive N2 lymph nodes. Eleven percent had T4 disease, and another 11% were found to have meta-static disease at the time of resection.

Sensitivity analysisIn order to determine if the relatively low incidence of mediastinal staging may have altered the results, we per-formed a sensitivity analysis by eliminating all patients who had positive N2 lymph nodes on postoperative pathology, on the assumption that they may have been positive before resection. For the patients with clinical stage I disease, this had no effect on survival analysis. For those with clinical stage II disease, there was a simi-lar trend, with decreased survival in those waiting more than 2 months; however, the results were no longer clinically signi�cant.

DISCUSSION

This retrospective cohort study examined the effect of surgical wait times in patients with clinical stage I and II NSCLC. For patients with clinical stage I disease, we identi�ed no effect of wait times up to 4 months on survival or incidence of upstaging. For patients with clinical stage II disease, those waiting longer than 2 months had an increased incidence of upstaging as well as decreased survival compared with those waiting less than 1 month.

A number of studies have previously been performed to assess the effect of surgical wait times on survival in patients with NSCLC. However, these studies combined patients across multiple stages, and some included patients treated both operatively and nonoperatively. Myrdal and col-leagues3 investigated the association between treatment delay and prognosis in 466 patients with NSCLC. Paradox-ically, they found that shorter delay was associated with poorer prognosis. They speculated that this �nding was due to selection bias, as patients with more severe signs and symptoms and perhaps more aggressive disease may have received more prompt treatment. Myrdal and colleagues3 included patients across all pathological stages, the majority of whom were stage III or IV. In a study by Buccheri and colleagues,4 delays in time between the presentation of �rst symptoms and consultation with a specialist were examined in 1277 patients with stage I–IV NSCLC. They found a small but statistically significant decrease in survival in patients with delays greater than 2 months compared with those who waited less than 2 months. This �nding is con-trary to those of other studies that found no correlation

Table 3. Stage I incidence of upstaging

Factor p value Odds ratio

Wait 0 to < 1 mo — 1.0

Wait 1 to < 2 mo 0.45 0.704

Wait 2 to < 3 mo 0.14 0.403

Wait 3 to < 4 mo 0.07 0.216

Histology 0.93 1.04

R0 resection 0.19 0.42

Sublobar resection 0.05 7.81 (favours sublobar)

Table 4. Stage II patient (n = 42) characteristics

Wait time group; mean ± SD or no. (%)

Characteristic 0 to < 1 mo 1 to < 2 mo 2 to < 3 mo

No. of patients 16 19 7

Age, yr 71 ± 7.2 67 ± 12 66 ± 8.0

Female sex 5 (29) 9 (47) 2 (29)

Tumour size, cm 5.47 ± 2.16 4.90 ± 1.77 5.39 ± 1.92

Adenocrcinoma 4 (24) 10 (56) 3 (43)

R0 resection 14 (88) 17 (94) 6 (85)


Fig. 2. Clinical stage II survival.

0.4

0.2

0.0

0 10 20 30 40

Survival in months

Cum

ulat

ive

surv

ival 0.8

0.6

1.0months

wait012

Fig. 1. Clinical stage I survival.

0.7

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Survival in months

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ive

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between delays in diagnosis or treatment of lung cancer and clinical outcome.5–8 In one of the largest studies, Aragoneses and colleagues2 failed to show any impact of therapeutic delay (de�ned as the interval from diagnosis to surgical resection) on survival in patients with NSCLC. All of these studies combined patients with various stages of NSCLC. To our knowledge, the present study is the only one to assess the effect of wait times on these outcomes with the analysis strati�ed based on stage.

Limitations

There are a number of limitations to our study. The small sample size leaves the possibility of a type I error in the analysis. For patients with clinical stage I disease, it is possi-ble that with a larger sample size, a subtle difference in sur-vival or upstaging with wait times may have been identi�ed. The small sample size with the stage II analysis also pre-cluded any adjustments of possible confounders. The retro-spective nature of the study was also a limitation. Patient comorbidities were not captured in this retrospective data set. For the �ndings in patients with stage II disease, it is conceivable that patients with more severe comorbidities may have had longer delays in order to optimize them for resection. This may have contributed to the �ndings of decreased survival in patients with stage II disease. If this were the case, however, we would have also expected to see decreased survival with increased wait times in patients with stage I disease. Had the effect of increased wait times on survival been confounded by patient comorbidities, adjust-ment for this bias would have eliminated the �nding of decreased survival with wait times longer than 2 months. This would therefore lend weight to the argument that wait times in this interval have no signi�cant effect on survival.

The patients in our study had a relatively low incidence of invasive mediastinal staging. One could argue that the results of this study could be biased by the potential inappropriate inclusion of patients who may have had positive mediastinal lymph nodes that were not identi�ed on preoperative PET scans. As mentioned, we performed a sensitivity analysis to assess for this, with no signi�cant impact on our �ndings. Had every patient undergone invasive mediastinal staging, it is unlikely that our conclusions would have been altered. Fur-thermore, elimination of this potential bias would be more likely to eliminate any effect of wait times on survival.

CONCLUSION

In patients with clinical stage I NSCLC, we failed to identify an effect of surgical wait times of up to 4 months on survival. In those with clinical stage II dis-ease, patients waiting longer than 2 months had signi�-cantly worse survival and increased incidence of upsta-ging than those who waited less than 2 months. Consideration should be given to prioritizing patients with clinical stage II NSCLC for more timely resection, while those with clinical stage I disease may be able to tolerate longer waits to achieve this goal. Broad recom-mendations for surgical wait times across all stages therefore may not be appropriate.Af�liations: From the London Health Sciences Centre, London, Ont. (Coughlin, Guidolin, Frechette, Malthaner, Inculet); and the Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS (Plourde).


Contributors: S. Coughlin, M. Plourde, D. Fortin, E. Frechette and R. Inculet designed the study. S. Coughlin and K. Guidolin acquired the data, which S. Coughlin, M. Plourde, R. Malthaner and R. Inculet analyzed. S. Coughlin wrote the article, which all authors reviewed and approved for publication.

References

1. Visser MRM, van Lanschot JJ, van der Velden J, et al. Quality of life in newly diagnosed cancer patients waiting for surgery is seriously impaired. J Surg Oncol 2006;93:571-7.

2. Aragoneses FG, Moreno N, Leon P, et al. Bronchogenic Carcinoma Cooperative Group of the Spanish Society of Pneumology and Thoracic Surgery (GCCB-S). Lung Cancer 2002;36:59-63.

3. Myrdal G, Lambe M, Hillerdal G, et al. Effect of delays on prognosis in patients with non-small cell lung cancer. Thorax 2004;59:45-9.

4. Buccheri G, Ferrigno D. Lung cancer: clinical presentation and special-ist referral time. Eur Respir J 2004;24:898-904.

5. Pita-Fernández S, Montero-Martinez C, Pertega-Diaz S, et al. Relation-ship between delayed diagnosis and the degree of invasion and survival in lung cancer. J Clin Epidemiol 2003;56:820-5.

6. Bozcuk H, Martin C. Does treatment delay affect survival in non-small cell lung cancer? A retrospective analysis from a single UK centre. Lung Cancer 2001;34:243-52.

7. Quarterman RL, McMillan A, Ratcliffe MB, et al. Effect of preopera-tive delay on prognosis for patients with early stage non-small cell lung cancer. J Thorac Cardiovasc Surg 2003;125:108-13.

8. Billing JS, Wells FC. Delays in the diagnosis and surgical treatment of lung cancer. Thorax 1996;51:903-6.


DISCUSSIONS IN SURGERY • DISCUSSIONS EN CHIRURGIE


A proposal for the curriculum and evaluation for training rural family physicians in enhanced surgical skills

T he precipitous attrition of small volume surgical programs in rural Canada over the past 2 decades has led to the need for rural Canadians to travel for even the most basic procedural care.1 The linkages

between sustainable rural maternity care and the presence of robust local sur-gical programs drive the need for a solution to sustain local surgical services beyond the intrinsic value they offer.2–4 The local bene�ts to these surgical programs include ensuring appropriate equity of access to health care ser-vices; increased community capacity to recruit and retain family physicians and other health care providers in rural settings; maintaining a high level of community health care competence, particularly in regards to critical care and emergency services; and providing the context for rural education and research. At a community level this translates into securing the availability of a surgical �rst responder trained to handle a variety of scenarios, such as trauma, that require immediate intervention. The obligation to travel for care is a substantial barrier to equitable access for rural Canadians. In western Canada, rural family physicians trained in enhanced surgical skills (ESS) working alongside general surgeons and other specialists underpin this essen-tial health care infrastructure.5,6

Presently, there is 1 accredited 12-month postgraduate training program for family physicians to acquire ESS training. The University of Saskatchewan accepts 2 trainees per year at its Prince Albert site. The University of Alberta appears poised to start a similar program at its Grande Prairie site.

The National Working Group on ESS represents a large number of volun-teers drawn from the shallow pool of those experienced and active in ESS training programs and practice in British Columbia, Alberta and Saskatch-ewan, along with interested national partners (http://ess.rccbc.ca/�fth-page/). This article has been crafted by our Curriculum Committee. Our goal has been to describe a generic training and evaluation program for ESS rural fam-ily physicians suitable for introduction at any of Canada’s medical schools. To our knowledge, this has never been done. With the recent recognition by the College of Family Physicians of Canada (CFPC) of ESS as a community of practice (CoP) section, there is a potential pathway to a certi�cate of added competence for ESS. We believe that a curriculum and evaluation framework, such as the one we propose, is an essential platform in this pathway.1

Nadine Caron, MD, MPH Stuart Iglesias, MD Randall Friesen, MD Vanessa Berjat, MD Nancy Humber, MD Ryan Falk, MD Mark Prins, MD Victoria Vogt Haines, MD Brian Geller, MD Fred Janke, MD Robert Woollard, MD Bret Batchelor, MD Jared Van Bussel, MD

See also the editorial on p. 364, the com-mentary by Warnock and Miles on p. 367 and the commentary by Vinden and Ott on p. 369

Presented to the Rural Surgery Forum at Rural and Remote Medicine, Victoria, BC, April 2013

Accepted for publication Mar. 17, 2015

Correspondence to: S. Iglesias Bella Bella Denny Island BC V0T 1B0 [email protected]

DOI: 10.1503/cjs.002215

Rural western Canada relies heavily on family physicians with enhanced sur-gical skills (ESS) for surgical services. The recent decision by the College of Family Physicians of Canada (CFPC) to recognize ESS as a “community of practice” section offers a potential home akin to family practice anesthesia and emergency medicine. To our knowledge, however, a skill set for ESS in Canada has never been described formally. In this paper the Curriculum Committee of the National ESS Working Group proposes a generic curriculum for the train-ing and evaluation of the ESS skill set.

SUMMARY

propose-iglesias.indd 419 2015-11-10 9:20 AM

DISCUSSIONS EN CHIRURGIE


TRAINING: FOR WHOM, WHERE, AND TO DO WHAT?

In the year 2000 there were 150 ESS rural family phys-icians sustaining local surgical programs in rural commun-ities in western and northern Canada.5 Although the num-ber of these programs has shrunk substantially (from 80 in 1995 to 55 in 2011), the number of ESS physicians has remained stable (140 in 2011; unpublished data, Society of Rural Physicians of Canada, 2011). There is some evi-dence that several of these smaller programs grew larger in volume, absorbing a workforce displaced from pro-grams that closed.

The proposed curriculum comprises a set of competen-cies drawn from

• the historical skill sets in which ESS physicians have provided services,6–8

• the skill sets for which there is good research evi-dence on the outcomes and safety of appropriately trained ESS physicians performing these proced-ures on selected patients in facilities with suitable health and human resources,9–22 and

• the present University of Saskatchewan R3 ESS training program.

Historically, training programs for ESS have recognized that acquired skills should be tailored to the needs and resources of the community where practice is intended. We support this opinion; however, we also appreciate that

• the integrity of ESS requires a core curriculum of de�ned competencies shared by all ESS graduates, not unlike the competencies acquired in any other medical or surgical discipline;

• the sustainability of rural small volume surgical programs requires a workforce with a generic port-able skill set; and

• surgical skills deemed reasonable but outside the routine spectrum of ESS require additional train-ing, evaluation and application for such privileges.

CURRICULUM

The curriculum is based on 23 integrated modules, with each module representing a clinical presentation that might be referred to a rural family physician with ESS training. Each of these modules documents the knowledge and the diagnostic, management and procedural skills required for each clinical presentation. Evaluation incudes documenting the minimum volume of clinical exposure (milestones) for that module. The 23 modules fall under 5 broad categories as follows.

Basic operative management

1) Surgery 101: antisepsis, hemostasis, incisions, stabiliza-tion, wound healing, suturing and instruments, physio-logic reaction to surgery, nutrition

2) Patient selection and preparation: surgical and anesthetic

3) Surgical decision-making: crew resource management/operating room (OR) decision-making, patient transfer decision and management, triage

Management of abdominal presentation in the nonpregnant patient in rural and remote settings

4) Abdominal wall mass or pain: herniorrhaphy 5) Acute right lower quadrant pain: appendicitis/

appendectomy, adnexal/ovarian disease 6) Gastrointestinal (GI) bleeding (upper and lower) 7) GI screening and surveillance (upper and lower) 8) Perianal presentations: hemorrhoids, infections,

warts

Management of pregnancy in rural and remote settings

9) Complications of labour and delivery: operative vagin al delivery, cesarean section, perineal trauma, uterine inversion, postpartum hemorrhage, retained placenta, advanced labour and risk management (ALARM), neo-natal resuscitation program (NRP)

10) First trimester pain and bleeding: dilation and curet-tage, ectopic pregnancy

Management of nonabdominal presentations in rural and remote settings

11) Integumentary lesions: skin, nails, subcutaneous lesions, ganglia, lipoma, small flaps, skin grafting, digit al amputation

12) Fertility: vasectomy, tubal ligation, essure13) Genitourinary disease: acute testicular/scrotal disease,

phimosis, circumcision, urethral dilation14) Nonpregnant uterine bleeding: dilation and curettage,

hysteroscopy15) Tonsillar disease: tonsillectomy, adenoidectomy16) Hand: carpal tunnel release, hand trauma/infection,

extensor tendon repair, compartment syndrome17) Other elective procedures

Basic principles

18) Laparoscopy principles and skills19) Endoscopy principles and skills20) Laparotomy principles and skills21) Procedural sedation principles and skills22) Emergency ultrasound principles and skills: emergency

department echo (EDE), emergency department tar-geted ultrasound (EDTU), focused assessment with ultra sound in trauma (FAST)

23) Hysteroscopy principles and skills


DISCUSSIONS IN SURGERY


EVALUATION

While it is anticipated that there will be some variation in the evaluative process between different ESS programs, there are substantive core principles that belong in all such programs.• Evaluation is continuous and comprehensive and is

embedded in each independent clinical encounter shared by a resident and preceptor, including all con-sultations and procedures. The evaluation should include the outcomes whether or not the encounter led to a surgical procedure.

• Evaluation should be measured as objectively as possible using something similar to an Objective Structured Assessment of Technical Skills (OSATS) form for technical skills and something equivalent that is appropriate for measuring the knowledge, diagnostic and management skills embedded in each ESS consultation.

• Evaluation should also include assessment that comes from a source external to the local training program.

Internal

The evaluation of an ESS resident’s knowledge and skills as well as their progress within each of the clinical mod-ules has 2 parallel tracks.• Volume of clinical exposure: within each module,

there are milestones for the volume of both consulta-tions and procedures. Success in each module requires that these milestones be attained.

• Veri�cation of competency: some measurement tool for competency will be completed for each independ-ent clinical encounter shared between a resident and a preceptor. Final success in each module requires sign-off by 2 preceptors on both the consultations and the procedures applicable to that module, verifying the resident’s suitability for independent practice.

External

The credibility of the internal evaluation process and the portability of its certi�cate of completion will be substan-tially larger with an external examination process. Equally important, the comfort felt by the preceptors who sign off on competence will be supported by the knowledge that the learner will be scrutinized in an external examination process. This external examination process ideally would include both an oral and written component.• Oral: an examination committee that includes an ESS

physician, an obstetrician–gynecologist and a general surgeon from outside the program would meet, either in person or remotely by video conference, and exam-ine an ESS resident using clinical scenarios taken from their log book and ESS curriculum. Each examiner

would obtain assessment scores using the same meas-urement tool used for scoring the ESS consultations. A sign-off would be required from 2 of the 3 examin-ers for success on this exam.

• Written: the ESS residents writing the Principles of Surgery examination, which is taken each spring by second-year specialty surgical residents in Canada, would be helpful assessment for topics not covered in clinical evaluations during rotations or oral exams.

CONCLUSION

The availability of safe, high-quality rural surgical services requires educational programs for the training, evaluation, and certi�cation of rural family physicians with ESS. The sustainability of a mobile ESS workforce with a certi�ed portable skill set will be enhanced by a pathway to a Cer-ti� cate of Added Competence in ESS from the CFPC, which they have now endorsed.23 We offer this proposal for the curriculum and evaluation of ESS training as a pil-lar to be considered in that evolution. The next step would be engagement with specialist partners whose expertise and mentorship are required to use this proposed platform to train ESS physicians with fellow ESS physicians.

Af�liations: From the Department of Surgery, University of Northern British Columbia, Prince George, BC (Caron); Bella Bella, Denny Island, British Columbia (Iglesias); the Department of General Surgery, University of Saskatchewan, Prince Albert, Sask. (Friesen); Rocky Mountain House, Alberta (Berjat); the Lillooet Medical Clinic, Lillooet, BC (Humber); the Inuvik Regional Hospital, Inuvik, Northwest Terri-tor ies (Falk, Prins); the Selkirk Medical Clinic, Revelstoke, BC (Vogt); the University of Saskatchewan, Meadow Lake, Sask. (Geller); Rural and Regional Health, University of Alberta, Sylvan Lake, Alta. (Janke); the Department of Family Medicine, University of British Columbia, Van-couver, BC (Woollard); the Omineca Medical Clinic, Vanderhoof, BC (Batchelor); and the Associate Clinic, Pincher Creek, Alta. (Van Bussel).



References

1. Pong RW, Pitblado JR. Geographic distribution of physicians in Canada: beyond how many and where. Ottawa: Canadian Institute for Health Research (CIHI); 2005.

2. Kornelsen JA, Grzybowski SW. Obstetric services in small rural communities: What are the risks to care providers? Rural Remote Health 2008;8:943.

3. Kornelsen J, Grzybowski S. Cultures of risk and their in�uence on birth in rural British Columbia. BMC Fam Pract 2012;13:108.

4. Kornelsen J, Grzybowski S, Iglesias S. Is rural maternity care sustainable without general practitioner surgeons? Can J Rural Med 2006;11:218-20.

5. Iglesias S, Jones L. Rural surgical programs in Western Canada. Can J Rural Med 2002;7:103.

6. Chaisson PM, Roy P. Role of the general practitioner in the delivery of surgical and anaesthesia services in rural western Canada. CMAJ 1995; 153:1447-52.




7. Humber N, Frecker T. Delivery models of rural surgical services in British Columbia (1996-2005): Are general practitioner-surgeons still part of the picture? Can J Surg 2008;51:173-8.

8. Humber N, Frecker T. Rural surgery in British Columbia: Is there anyone out there? Can J Surg 2008;51:179-84.

9. Society of Rural Physicians of Canada, Society of Obstetricians and Gynecologists of Canada, & College of Family Physicians of Canada. Joint position paper on training for rural family practitioners in advanced maternity care skills including cesarean section. Can Fam Physician 1999;45:2416-22.

10. Deutchman M, Conner P, Gobo R, et al. Outcomes of cesarean sec-tions performed by family physicians and training they received; a 15 year retrospective study. J Am Board Fam Med 1995;8:81-90.

11. Kriebel SH, Pitts JD. Obstetric outcomes in rural family practice: an 8 year experience. J Fam Pract 1988;27:377-84.

12. Cameron B, Cameron S. Outcomes in rural obstetrics, Atherton Hospital 1981-90. Aust J Rural Health 2001;9:S39-42.

13. Black DP, Fyfe IM. The safety of obstetric services in northern Ontario. Can Med Assoc J 1984;130:571-6.

14. British Columbia Reproductive Care Program. Report on the �nd-ings of a consensus conference on obstetrical services in rural and remote communities. Can J Rural Med 2000;5:221-217.

15. Iglesias S, Saunders LD, Tracy N, et al. Appendectomies in rural hospitals: safe whether performed by specialist or GP surgeons. Can Fam Physician 2003;49:328-33.

16. Caron NR, Lewis-Watts DA, Weber EM. The provision of emer-gency surgical services in isolated communities. JCC 1998;41:8.

17. Rodney WM, Hocutt JE Jr, Coleman WH, et al. Esophagogastro-duodenoscopy by family physicians: a national multisite study of 717 procedures. J Am Board Fam Pract 1990;3:73-9.

18. Harper MB, Pope JB, Mayeaux EJ Jr, et al. Colonoscopy experience at a family practice residency: a comparison to gastroenterology and general surgery services. Fam Med 1997;29:575-9.

19. Kirby E. Colonoscopy procedures at a small rural hospital. Can J Rural Med 2004;9:89-93.

20. Rodney WM, Debon G, Cronin C. Evolving colonoscopy skills in a rural family practice: the �rst 293 cases. Fam Pract Res J 1993;13:43-52.

21. Pierzchajlo RP, Ackerman RJ, Vogel RL. Colonoscopy by a family physician: a case series of 751 procedures. J Fam Pract 1997;44: 473-80.

22. Hopper W, Kyker KA, Rodney WM. Colonoscopy by a family phys-ician: a 9 year experience of 1048 procedures. J Fam Pract 1996;43: 561-6.

23. Lemire F. Calibrating. Can Fam Physician 2015;61(7):648.

The detailed curriculum proposal is available at http://rccbc .ca /wp-content/uploads/2014/10/Draft-2-Enhanced-Surgical -Skills-Curriculum-14-01-21.pdf

We believe in open access to researchTo ensure continued worldwide free access to all CJS content, articles submitted for publication as of Jan. 1, 2014, are subject to a submission fee of $100 (Canadian funds). Submission fees will be waived for corresponding authors af�liated with CJS sponsors.

Accepted Research, Review and Continuing Medical Education articles are subject to a publication fee of $700, and Commentaries and Discussions are subject to a publication fee of $500, payable on acceptance in Canadian funds.

Benefits of open access

• For researchers and institutions: increased visibility, usage and impact for their work• For government: a better return on investment for funding research• For society: ef�cient, effective patient care resulting in better outcomes

CJS articles are available free of charge on the journal website (canjsurg.ca) and in PubMed Central.




The importance of tailoring physicians’ trauma care training needs in rural environments

F or a trauma system to have the maximal survival bene�t, severely injured patients must survive long enough to reach trauma centre care. This objective is challenging, particularly in more rural

environ ments where discovery and transport times might be prolonged. In this context, a component of care delivered in either lower-level or nondesignated centres is critical. In rural environments, these are often small community hospitals where the resources for evaluation and man-agement are few and the experience of providers is limited.1 While focused courses to enhance the knowledge and skills of providers have shown bene�t, we sought to evaluate the current status and perceived educational needs of physicians working in emergency departments (EDs) across several regional trauma systems in Canada. The principle objective was to identify opportunities to better prepare physicians working in more rural environments.

We designed a cross-sectional survey to evaluate the current status and perceived educational needs of emergency physicians who might be responsible for the initial evaluation and management of major trauma patients. The content of the survey was guided by formative research, consisting of 2 focus groups and a field test. Our population of interest was physicians working in the EDs of non–trauma centres or level III–V trauma centres located at least 30 minutes from the nearest level I or II trauma centre. We identified a total of 382 hospitals across 7 provinces (British Columbia, Alberta, Ontario, New Brunswick, Newfoundland and Labrador, Nova Scotia and Prince Edward Island) meeting our inclusion criteria.

Survey data were collected in 2 waves, October 2011 and December 2012, following identical procedures. Survey packages containing a cover letter, an information and instruction guide, a consent form, a ques-tionnaire and a prepaid return envelope were mailed to selected phys-icians. For the initial survey 2196 physicians were selected and for the second wave 367 additional physicians were selected, for a total of 2563 phys icians. Exploration of regional differences and needs across the rural–suburban continuum are available in Appendix 1 (available at canjsurg.ca).

Payam Tarighi, MD, PhD Jill E. Sherman, MPH Oxana Mian, MA Avery B. Nathens, MD, PhD

This study was presented in part as a poster at the 73rd annual meeting of the American Association for the Surgery of Trauma, Sept. 10–13, 2014, Philadelphia, PA

Accepted for publication Apr. 13, 2015

Correspondence to: P. Tarighi Sunnybrook Health Sciences Centre Evaluative Clinical Sciences 2075 Bayview Ave. Rm K3W-27 Toronto ON M4N 3M5 [email protected]

DOI: 10.1503/cjs.002315

Gaps in the provision of care exist in the initial evaluation and management of patients �rst cared for in the most rural settings. We designed a survey to explore what unmet educational needs might exist so as to improve the care of patients before transfer. Here we discuss opportunities for tailored training that will enhance learning capacity, narrow the trauma education gap and improve trauma care, particularly in rural environments.

SUMMARY

tailor-tarighi.indd 423 2015-11-10 10:46 AM



STRUCTURED EDUCATIONAL OPPORTUNITIES

We identi�ed opportunities to enhance training through structured learning opportunities. Physicians indicated difficulty in accessing Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) courses, and there was lack of awareness about newer trauma educational opportunities, such as the Rural Trauma Team Development Course (RTTDC). Limita-tions to accessing ATLS might explain why one-third of physicians did not have recent ATLS certi�cation, even though most (80%) respondents felt it would meet their educational needs. The positive impact of courses like ATLS on physicians’ knowledge and skills has been docu-mented, and there are strong recommendations that ATLS should be taken by any physician involved in the care of injured patients.2 Many physicians indicated a pref-erence for training courses in their communities, empha-sizing the value of either using telemedicine as a medium for ATLS delivery or having experts provide courses locally.3 Increasing the cadre of ATLS instructors from more rural centres may also improve the availability of ATLS courses outside of major cities.

Interestingly, there was limited awareness of or experi-ence with the RTTDC; this might be a re�ection of either its relative novelty compared with ATLS, lack of awareness among trauma training providers in Canada or the avail-ability of similar alternatives. Other rural-focused training courses reported by participants included the Combined Advanced Life Support Course (CALS) with Trauma Module and the Comprehensive Approach to Rural Emer-gencies (CARE) Course developed in British Columbia.

Knowledge/expertise gaps among rural providers

There were speci�c areas that physicians identi�ed as par-ticularly challenging and for which additional educational opportunities would be helpful. Three-quarters of partici-pants expressed interest in content related to pediatric trauma, orthopedic/peripheral vascular trauma, airway management and blunt chest/abdominal trauma. These potential gaps are almost certainly related to the relative infrequency with which they are confronted by these problems. A major challenge for improving the impact of training lies in helping physicians maintain knowledge and skills in environments with limited exposure to major trauma. Many physicians in rural environments might see fewer than 5 patients with severe injuries per year.

Preferences in mode of learning

Having rural physicians travel to major urban areas for didac-tic lectures is suboptimal, drawing physicians away from where they are most needed. Further, we identified that respondents’ preferred mode of learning was practice-

oriented, with a distinct preference for simulation-based training. The integration of simulation into ATLS is a chal-lenge, but one that might serve providers and patients well.

EDUCATION AND SUPPORT IN PRACTICE

This survey identified gaps in training opportunities, knowledge and experience of physicians responsible for the initial care of injured patients in rural environments. Structured learning opportunities like ATLS are dif�cult to access for rural physicians. The RTTDC is likely more suitable for the most rural environments and provides teams with an understanding of what they can accomplish together using their own resources. Unfortunately, promulgation of RTTDC in Canada has been limited. Leaders in trauma care should take the responsibility of raising awareness of opportunities like these to enhance the care of patients in their regions. Where possible, simulation-based training should be incorporated to provide rural practitioners with hands-on experience with their local teams.

The reality of infrequent exposure and potential delays in transfer related to weather and/or transport need can’t be ignored. Physicians in regional trauma centres need to better support their rural providers in real-time through telemedi-cine and/or teleresuscitation. Additionally, providing struc-tured feedback to providers based on patients transferred from their institutions brings an educational opportunity to every practice encounter.4 Taken together, telemedicine with real-time consultation and remote learning opportunities might very well improve trauma care in rural settings.5

Our survey had several potential limitations. Recall bias may have been introduced when physicians were asked about their past practices and training courses. Addition-ally, our low response rate (nearly 20%) leads to the poten-tial of nonresponse bias, where physicians electing not to participate might have had very different perspectives on educational needs and gaps. Moreover, given the expected challenges with response rates, we opted for perceived knowledge gaps over actual ones to try to get a little closer to providing these physicians with something from which they might be able to bene�t. However, one of our major strengths was the diversity of physicians participating, with representation of those certi�ed in emergency medicine and those without such credentials, and the broad geo-graphic representation from across Canada. Furthermore, we used a combination of quantitative and qualitative approaches to ensure a full spectrum of responses.

We believe that the delivery and content of trauma edu-cation materials should be tailored based on the needs of providers, as the practice setting and physicians’ experi-ences call for very different requirements. This work focused on providers practising outside of major urban areas who have different interests and needs related to con-tent and mode of delivery than providers in the most urban




areas. The ATLS, PALS and other trauma educational offerings should be more accessible, and greater use of tele-education should be considered. Furthermore, courses focusing on trauma team approaches in the context of scarce resources (e.g., RTTDC) need greater promotion and emphasis. We believe that educational opportunities will be more effective if learning is based on real cases from the local setting, and real-time consultation will provide physicians the training and support they require to in turn provide optimal care in the most rural environments.

Af�liations: From the Sunnybrook Health Sciences Centre, Toronto, Ont. (Tarighi, Nathens); the Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ont. (Sherman, Mian); and the Department of Surgery, University of Toronto, Toronto, Ont. (Nathens).

Funding: Funding for this work was received from the Canadian Insti-tutes of Health Research. A. Nathens is supported by the de Souza Chair in Trauma Research.



References

1. Helling TS. The challenges of trauma care in the rural setting. Mo Med 2003;100:510-4.

2. Mohammad A, Branicki F, Abu-Zidan FM. Educational and clinical impact of Advanced Trauma Life Support (ATLS) courses: a system-atic review. World J Surg 2014;38:322-9.

3. Ali J, Sorvari A, Camera S, et al. Telemedicine as a potential medium for teaching the Advanced Trauma Life Support (ATLS) course. J Surg Educ 2013;70:258-64.

4. Duchesne JC, Kyle A, Simmons J, et al. Impact of telemedicine upon rural trauma care. J Trauma 2008;64:92-7, discussion 7-8.

5. McCrum ML, McKee J, Lai M, et al. ATLS adherence in the trans-fer of rural trauma patients to a level I facility. Injury 2013;44:1241-5.

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Trends in the Canadian Surgery Forum (CSF): analysis of the CSF program over the past decade

T he evolution of the Canadian Surgery Forum (CSF) over the past decade has been remarkable. More speci�cally, it re�ects the increas-ing importance of subspecialty scienti�c content, relevant continuing

medical education and improvements in care within both traditional and new subspecialty societies under the umbrella of the CSF itself. The scienti�c content within any national surgical congress provides an important com-mentary on the status and evolution of care within that given country. More speci�cally, it may act as a barometer of innovation as well as the quality of both clinic care and health care systems (i.e., regionalized care). These con-ferences and embedded scienti�c topics also stimulate new directions in clin-ical care, future research and, not uncommonly, an evaluation of one’s own practice and/or hospital system upon returning home.

While the science behind any individual subspecialty topic tends to fol-low a “recognition–momentum–plateau” pattern,1 the more relevant query for the CSF is the evolution of scienti�c content within the pro-gram itself. Changes in the scienti�c presentations re�ect the increasing relevance of certain topics with a concurrent reduction in focus on others. These trends can be driven by technical developments, public health issues, reorganization of health systems and/or changing interests among new generations of surgeons.

Given the importance of understanding past progress and challenges to help de�ne the future, we sought to de�ne the volume, type and methodol-ogy of the scienti�c content within the CSF over the past decade. To this end, all scienti�c abstracts that were presented at the CSF (oral or poster) from 2004 to 2013 were independently reviewed by our group for topic/ subspecialty volume, scienti�c content, methodology2 and the geographical region of origin.

A total of 1214 scienti�c abstracts were presented in oral or poster for-mat during the study interval (2004–2013). The total volume of presented abstracts per year increased signi�cantly over time from a low of 107 in 2004 to a high of 195 in 2012 (Fig. 1). This clearly re�ects an enhanced commitment of the CSF to original scienti�c contributions. It is also inter-esting to note that this increase in abstract volume correlates with a con-current increase in overall conference attendance (538 attendees in 2004

Chad G. Ball, MD, MSc Tammy L. Eberle, RN Elijah Dixon, MD, MSc Cassandre Boland, BA

This paper was presented at the Canadian Surgery Forum in Vancouver, BC, Sept. 17–19, 2014.

Accepted for publication Apr. 13, 2015

Correspondence to: C.G. Ball University of Calgary Foothills Medical Centre 1403 – 29 St NW Calgary AB T2N 2T9 [email protected]

DOI: 10.1503/cjs.015314

Numerous clinical and basic science–related innovations have been presented at the Canadian Surgery Forum (CSF). We sought to de�ne changes in both the content and methodology of the CSF scienti�c program over the past decade. While the total volume of CSF abstract presentations has increased dramatically, the methodological quality has remained static, with few randomized trials and minimal prospective work. Although the majority of the scienti�c content is asso-ciated with urban university centres, the program also encourages content from community practices. Surgical education, hepatopancreatobiliary and bariatric content have increased substantially, but remain secondary to colorectal diseases.

SUMMARY


trends-ball.indd 426 2015-11-10 9:22 AM

DISCUSSIONS IN SURGERY


and 707 attendees in 2012). Although the geographic distribution of abstracts was consistent across years, it was not directly related to the population within a given province. More speci�cally, the mean (range) distribu-tion was 49% (43%–60%) from Ontario, 18% (13%–21%) from Quebec, 10% (9%–11%) from Alberta, 8% (6%–12%) from British Columbia and 15% (4%–19%) from other provinces. Interestingly 9% of all abstracts were not directly affiliated with a University centre. Although this was consistent over time, it re�ects the continued importance of community surgery perspect-ives that include advancing clinical care, human resource needs, resource limitations and a wide breadth of practice. This content must be encouraged and fos-tered moving forward.

The relative proportions among subspecialty topics were also consistent over the decade. Not surprisingly given the commonality of the topic across nearly all surgical subspecialties, colorectal diseases remained the dominant area of focus (mean 26%, range 18%–33%). Additional topics included surgical/medical education (mean 20%, range 8%–27%), thoracics (mean 10%, range 5%–13%), hepatopancreatobiliary (HPB; mean 9%, range 2%–15%), upper gastrointestinal (mean 8%, range 1%–10%), breast (mean 7%, range 4%–9%), bari atrics (mean 6%, range 1%–8%), trauma (mean 6%, range 1%–8%) and other areas (mean 8%). Three of these subspecialties displayed substantial growth in their scientific footprint: surgical/medical education (8% in 2004 v. 27% in 2012), HPB (2% in 2004 v. 15% in 2013) and bariatrics (1% in 2004 v. 10% in 2013) all dramatically increased the volume of their presenta-tions (Fig. 2). This reflects the relatively new and momentum-building evolution of each of these sub-specialties; to our knowledge, this is the �rst report of this �nding across a large multisubspecialty meeting within surgery. Interestingly, only trauma-related topics showed a signi�cant decrease in footprint over

the decade (11% in 2004 v. 3% in 2013). Also not sur-prisingly, the majority (91%) of noneducation-based abstracts discussed clinical care.

In addition to the specific content of the abstract, methodological quality/type remains an important factor to both improve the quality of a surgical congress and to parlay these topics into subsequent improvements in actual clinical care. The quality of methodology among the CSF scienti�c abstracts was consistent across the study interval. The majority were retrospective (mean 76%, range 66%–81%), with an additional 12% each engaging in prospective and survey techniques. This �nding re�ects the continued need to strive for prospective studies and trials as a surgical community within Canada. It also has a clear and direct link to support from funding agencies and university departments. Despite the retrospective pattern of CSF studies, the median number of study participants across all projects was 895. This represents a relatively large average cohort and therefore greater potential rele-vance to our �eld.

The evolution of the scienti�c content within a national surgical congress is in�uenced by numerous factors. These include, but are not limited to, revolutionary antidogmatic concepts, persuasive speakers, dominant institutions, pro-gram committee viewpoints and general clinical patient issues.3 In an ideal setting, the peer-reviewed abstract pre-sentations mirror clinical needs for the improvement of patient care and increase in methodological quality as time progresses. Without a regular and objective rearview evalu-ation of our CSF, however, we will not be able to �ne-tune our pathway forward.

In summary, the CSF program has dramatically increased in terms of the volume of scienti�c abstract pre-sentations, but it has remained static in terms of methodol-ogy over the past decade. It has also observed a large

Fig. 1. Total number of Canadian Surgery Forum scientific abstract presentations from 2004 to 2013.

0

50

100

150

200

250

No.

of

pres

enta

tions

2004Year

2013

Fig. 2. Growth in subspecialty topics in the Canadian Surgery Forum program from 2004 to 2013. HPB = hepato pancreatobiliary.

0%

5%

10%

15%

20%

25%

30%

Surgical/medical education

Bariatrics

HPB

Pro

port

ion

of t

opic

s, %

2004Year

2013




growth in education, HPB and bariatric content footprints. As a national congress, we need to continue to encourage pro-spective subspecialty and relevant community-driven content.Af�liations: From the Department of Surgery, University of Calgary, Calgary, Alta. (Ball, Eberle, Dixon); and the Canadian Surgery Forum, Ottawa, Ont. (Boland).



References

1. Balogh ZJ, van Wessem K, Yoshino O, et al. Postinjury abdominal compartment syndrome: Are we winning the battle? World J Surg 2009;33:1134-41.

2. Oxford Centre for Evidence-based Medicine Levels of Evidence. (May 2011) CEBM website. Available: www.cebm.net (accessed 2014 Jan 14).

3. Ball CG, Sutherland FR, Kirkpatrick AW, et al. Dramatic innova-tions in modern surgical subspecialties. Can J Surg 2010;53:335-41.

CJS’s top viewed articles*

1. Research questions, hypotheses and objectives Farrugia et al. Can J Surg 2010;53(4):278-81

2. Blinding: Who, what, when, why, how? Karanicolas et al. Can J Surg 2010;53(5):345-48

3. Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon’s guide

Sarkhosh et al. Can J Surg 2013;56(5):347-52

4. Managing complications associated with laparoscopic Roux-en-Y gastric bypass for morbid obesity

Sahle Grif�th et al. Can J Surg 2012;55(5):329-36

5. De�ning medical error Grober and Bohnen Can J Surg 2005;48(1):39-44 6. Tracheostomy: from insertion to decannulation Engels et al. Can J Surg 2009;52(5):427-33

7. Hardware removal after tibial fracture has healed Sidky and Buckley Can J Surg 2008;51(4):263-8

8. Treatment of an infected total hip replacement with the PROSTALAC system Scharfenberger et al. Can J Surg 2007;50(1):24-8

9. Pharmacological management of postoperative ileus

Zeinali, et al. Can J Surg 2009;52(2):153-7

10. All superior pubic ramus fractures are not created equal Steinitz et al. Can J Surg 2004;47(6):422-5

*Based on page views on PubMed Central of research, reviews, commentaries and discussions in surgery. Updated Nov. 10, 2015.




Signi�cance of CD4+ T-cell count in the management of appendicitis in patients with HIV

A ppendicitis has been described in connection with HIV infection, and initially researchers emphasized higher incidence and etio-logic al uniqueness in patients with HIV. In particular, opportunis-

tic infection has been considered to be connected to the pathogenesis of acute appendicitis or an appendicitis-like condition among patients with HIV. In addition, earlier studies of patients with appendicitis who had HIV revealed increased risk of perforation and high perioperative mortal-ity. Some authors suspect that a depressed level of cell-mediated immune response and delay in surgical interventions increase complication in patients with HIV. Other authors reported that lack of elevated white blood cell (WBC) count and delay in presentation to the emergency department were responsible for the higher morbidity and mortality. The general consensus among researchers is that accurate diagnosis is a key to successful management.

Gangrenous appendicitis, appendicitis with perforation and appendicitis with abscess formation are often collectively called complicated appendi-citis (CA) because of the higher morbidity and mortality. Some laboratory markers, such as elevation of WBC and C-reactive protein (CRP) levels, have been found to be useful for the diagnosis of CA. Moreover, studies have proven the importance of various computed tomography (CT) �nd-ings in the context of diagnosis of appendicitis, including discontinuity of the appendiceal wall, appendiceal diameter, appendicolithiasis and retro-peritoneal involvement. Various clinical parameters have been investigated to identify CA. However, to our knowledge, no previous study has been conducted to identify CA in patients with HIV.

We studied 322 patients in whom appendicitis was diagnosed at a single urban university hospital (tertiary referral centre for patients with HIV) between Jan. 1, 2007, and Dec. 31, 2012 (119 female, 203 male). The mean age was 31 (range 4–94) years. Patients were assigned to the CA group if perforation of the appendix, abscess formation, or purulent peri-toneal �uid was described in surgical reports; if histology reports indicated

Kumiko Kitaoka, MD, PhD Kazuhiro Saito, PhD Koichi Tokuuye, PhD


Correspondence to: K. Kitaoka Department of Radiology Tokyo Medical University Hospital 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan [email protected]

DOI: 10.1503/cjs.015714

Identi�cation of complicated appendicitis (CA) is critical to the management of appendicitis. However, previous studies have not investigated indicators of CA among patients with HIV or whether it is safe to use conservative treat-ment for appendicitis in these patients. Among 322 patients with appendicitis, we identi�ed 14 who had HIV. Six of them were operated and 8 were treated with antibiotics; CA was diagnosed in 4. Patients with HIV and CA had a sig-ni�cantly lower CD4+ T-cell count than those with uncomplicated appendi-citis. A white blood cell count lower than 7.4 × 109/L was observed exclusively in patients with CA. No patient with HIV whose appendicitis was treated conservatively died or experienced a recurrence. We discuss our �ndings, which suggest the possibility of conservative treatment of appendicitis in patients with HIV and identi�cation of CA by low CD4+ T-cell count.

SUMMARY

significant-kitaoka.indd 429 2015-11-10 9:49 AM



perforation of the appendix, abscess formation, periton-itis, or gangrenous appendicitis; or if abscess was found in proximity to the appendix on CT and appendiceal rupture was the only possible explanation after all diag-nostic examinations had been conducted. The remaining patients were included in the uncomplicated appendi-citis (UA) group. In all, 121 patients had CA (37.5%). All multidetector noncontrast or contrast CT images were reviewed for signs of appendicitis, abscess, perfora-tion and appendicolithiasis and for maximal appendiceal diameter. Data on baseline characteristics, WBC, CRP, CD4 level and serum RNA detection were retrieved from medical records.

Patients were divided into 2 groups depending on their HIV seropositivity. Fourteen patients (13 men, 1 woman, mean age 37 yr) had HIV (4.3%; Table 1). As to radiographical signs, appendicolith was observed in only 4 patients with HIV despite it being commonly associated with appendicitis and CA in the general popu lation. The mean diameter of the appendix was similar in both groups.

Ten patients with HIV were admitted and treated with antibiotics (71.4%), and 4 were treated as outpatients with antibiotics (28.6%). Surgery was performed in 6 patients, including all 4 patients with appendicolithiasis.

In total, CA was diagnosed in 121 patients, 4 of whom had HIV. Immunosuppression was associated with CA in both groups: CA was found in 3 of 4 (75%) patients in whom HIV had progressed to AIDS, in both patients with chronic kidney disease, in the only patient who had undergone bone marrow transplant, in 1 of 2 patients with liver cirrhosis and in 2 of 3 patients with diabetes.

There were some distinguishing clinical features among patients with CA who also had HIV. Notably, CD4+ T-cell count was signi�cantly lower in those with CA than in those UA (222.5 v. 571.0 cells/mm3, p =

0.023). Three of the 4 patients with HIV and CA had HIV RNA detection. The mean WBC count in these 4 patients was considerably lower than in patients with HIV and UA (6.8 v. 14.9 × 109/L). A WBC count lower than 7.4 × 109/L was observed exclusively in patients with both HIV and CA. Lower CRP level was also more fre-quent in these patients (41.0 v. 96.2 nmol/L). Immuno-suppression was related to the presence of CA in patients with HIV. Finally, larger appendiceal diameter, which is associated with severe appendicitis in the general popula-tion, was also associated with CA in patients with HIV.

There were no hospital deaths in either group. There was no readmission associated with nonoperative man-agement in the HIV-positive group. Thirteen of the patients with HIV continued regular follow-up at the HIV clinic for more than 20 months. None of these patients experienced a recurrence of appendicitis or died from illness during the follow-up period.

Our study showed higher risk of CA among immuno-suppressed patients and in patients with HIV who had lower CD4+ T-cell counts. This �nding is in agreement with previous reports that CD4+ T-cell count reduction was associated with increased all-cause morbidity and mortality. Low WBC count is another indicator of CA in patients with HIV. Importantly, a CT �nding of large appendiceal diameter served as an indicator of CA regardless of the status of HIV infection. These �ndings highlight the importance of identi�cation of CA and suggest the possibility of conservative treatment among selected patients with HIV. More studies are needed to investigate the effectiveness of conservative manage-ment in patients with HIV.

Acknowledgements: The authors thank Dr. You Tajima and Mr. Hirokazu Aoki for their assistance.

Af�liations: All authors are from the Radiology Department, Tokyo Medical University, Tokyo, Japan.


Contributors: All authors contributed substantially to writing and/or revising and to the conception and design of the manuscript and approved the �nal version for publications.

References

1. Flum DR, Steinberg SD, Sarkis AY, et al. Appendicitis in patients with acquired immunode�ciency syndrome. J Am Coll Surg 1997; 184:481-6.

2. Giiti GC, Mazigo HD, Heukelbach J, et al. HIV, appendectomy and postoperative complications at a reference hospital in Northwest Tanzania: cross-sectional study. AIDS Res Ther 2010;7:47.

3. Bova R, Meagher A. Appendicitis in HIV-positive patients. Aust N Z J Surg 1998;68:337-9.

4. Kitaoka K, Saito K, Tokuuye K. Important CT �ndings for predic-tion of severe appendicitis: involvement of retroperitoneal space. World J Emerg Surg 2014;9:62.

5. Deeks SG, Phillips AN. HIV infection, antiretroviral treatment, age-ing, and non-AIDS related morbidity. BMJ 2009;338:a3172.

Table 1. Comparison of clinical variables in patients with HIV

Group; mean (95% CI)*

Category CA, n = 4 UA, n = 10 OR (95% CI)

Appendix diameter, mm

14.4 (10.7–18.1) 9.7 (6.6–12.8) —

Appendicolith, no. 2 2 4 (0.3 –48.7)

CD4+ T-cell count, cells/mm3†

222.5 (19.6–425.5)

571.0(402.2–739.9)

—

RNA detection† 3 4 3.8 (0.3–51.4)

WBC count, × 109/L‡

6.8 (6.2–7.4) 14.9 (9.6–20.2) —

CRP level, nmol/L 41.0 (0–83.9) 96.2 (39.1–153.3) —

Age, yr 33.8 (27.8–39.8) 37.7 (33.9–41.5) —

Sex, male:female 4:0 9:1 —

CA = complicated appendicitis; CI = con�dence interval; CRP = C-reactive protein; OR = odds ratio; UA = uncomplicated appendicitis; WBC = white blood cell. *Unless otherwise indicated. †In 1 patient with UA, CD4 count and RNA detection were not obtained. ‡Shapiro-Wilk normality test = 0.8717, p = 0.044; Fisher exact test = 12.6, p = 0.07.

significant-kitaoka.indd 430 2015-11-10 9:49 AM



A comparison of outcomes between laparoscopic and open appendectomy in Canada

A ppendicitis is one of the most common surgical conditions in North America, affecting 8% of the population within their lifetime.1 First described by McBurney in 1894,2 appendectomy remains the stan-

dard of care for appendicitis. Until the introduction of the laparoscopic approach by Semm in 1983,3 however, little had changed with regard to surgical technique for almost a century. Since its initial description as a fea-sible procedure, a multitude of publications have compared laparoscopic (LA) with open appendectomy (OA). Among these studies, the method-ological quality ranges from moderate to poor, with many lacking random-ization, few blinding investigators, and most analyzing data without apply-ing intention to treat principles.4

In a recent meta-analysis by Sauerland and colleagues4 (56 studies com-paring LA versus OA), signi�cant decreases were noted in wound infection rate, length of hospital stay, postoperative pain and time to return to work in patients who received LA. Unfortunately, LA also displayed an increased risk of intra-abdominal abscesses.4 A recent large database study analyzing the Nationwide Inpatient Sample (NIS; 2006–2008) also identi-�ed lower overall morbidity, mortality and shorter hospital stays for LA than OA.5

Despite these studies supporting the safety and potential advantages of LA, debate remains in Canada as to the best surgical approach. This is evi-dent by the observation that 28% of appendectomies within the NIS data-base are still being performed using open techniques.5 As a result, we used both the Discharge Abstract Database (DAD) from the Canadian Institute for Health Information (CIHI) and Hospital Morbidity Database (HMDB) to compare LA with OA for the treatment of acute appendicitis in Canada. In particular, we assessed the rates of LA versus OA over time (2004–2008) as well as the outcomes for both procedures across pediatric, adult and elderly populations.

Although this Canada-wide analysis of 105 882 patients (2004–2008) dis-played similar characteristics to preceding publications comparing LA and OA (mean age 32 yr; male patients 55%; mean length of stay 2.9 d;

Christopher Blackmore, MD Divine Tanyingo, BSc Gilaad G. Kaplan, MD, MPH Elijah Dixon, MD, MSc Anthony R. MacLean, MD Chad G. Ball, MD, MSc

This paper was presented at the Digestive Diseases Week (DDW) in Chicago, Illinois, 2014.

Accepted for publication Oct. 1, 2015

Correspondence to: C.G. Ball University of Calgary Foothills Medical Centre 1403 – 29th St. N.W. Calgary AB T2N 2T9 [email protected]

DOI: 10.1503/cjs.012715

The bene�t 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 Infor-mation 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 fre-quent, the associated length of stay, postoperative complication rate and mortality are clearly lower than for OA. As a result, we support the contin-ued increase in use of LA with regard to both safety and outcomes.

SUMMARY

open-ball.indd 431 2015-11-10 10:01 AM



Charlson Comorbidity Index [CCI] score of 0 was 96%, CCI 1 was 2.9%, and CCI > 1 was 1%; rate of nonper-forated appendicitis was 69%; laparoscopic approach in 48% of cases), the odds of female patients undergoing LA were 1.26 times higher than the odds of male patients. Furthermore, the odds of a patient with a CCI of 0 under going LA were 1.35 times higher than patients with a CCI of 1 or more, and the odds of undergoing LA were 1.38 times higher for patients with nonperforated than perforated appendicitis. Patients between 20 and 49 years of age were also more likely to receive LA than both younger and older cohorts. Numerous theories as to why these trends have evolved in Canada are intri-guing and include the increased diagnostic capabilities of laparoscopy, improved surgeon comfort with the laparo-scopic approach and poorer comfort levels with tradi-tional open techniques among recent trainees.

Aside from patient-speci�c factors that affect the choice of surgery, we identi�ed geographical differ-ences in the rate of LA. In particular, there is a trend toward the increasing use of LA in western (British Columbia, Alberta, Saskatchewan, Manitoba) and cen-tral (Ontario) Canada compared with Atlantic Canada (Prince Edward Island, Nova Scotia, New Brunswick and Newfoundland). Lower rates of LA in Atlantic Canada may relate to surgeon preference or to overall lower health care expenditures in these regions.

In addition to the observed trends in our analysis favouring LA for certain patient populations, our results clearly support the overall safety of LA compared with OA in the Canadian context. Although the overall complica-tion rate was lower in the LA than the OA group (3.2% v. 5.3%), specific complications, such as intra-abdominal abscess and postoperative obstruction, were also reduced in the LA population. To our knowledge, this is the �rst large database confirmation of these findings. While decreased overall morbidity, mortality and length of stay are supported by prior research, the observed decrease in intra-abdominal abscess in patients who received LA con-trasts the results of prior large studies.4 This important novel �nding likely represent changes in the LA technique over time. More speci�cally, the decreased use of copious irrigation and increased skill of surgeons using this tech-nique are important contributors. Furthermore, in addi-tion to the overall length of stay being shorter among patients undergoing LA than those undergoing OA (2.3 v. 3.5 d), this surgical time frame has now anecdotally been

converted into a day procedure among many patients with nonperforated appendicitis.

During the period 2004–2008, there was clearly a linear trend toward increasing use of LA (36% in 2004 v. 59% in 2008). While this pattern closely mirrors those observed in other industrialized nations, the 2008 rate of LA remains comparably lower in Canada than in the United States (59% v. 72%).5 The trend toward LA likely reflects an increasing acceptance of the lower morbidity and mortality associated with the laparoscopic technique. We expect this trend to continue, with recent literature con�rming the superior cost effective-ness of LA.

In summary, our analysis demonstrates an increasing trend toward LA for the treatment of acute appendicitis in Canada. While there remain certain patient character-istics that may in�uence the decision to choose LA over OA (patient age, female sex and perforation), evidence supports the safety pro�le for LA. Overall, LA is associ-ated with decreased morbidity, mortality and length of stay. This is particularly relevant to fewer observed intra-abdominal abscesses and postoperative bowel obstructions. Based on these �ndings, LA appears to be a superb option for the management of acute appendicitis across all patient populations and should be encouraged.Af�liations: From the Department of Surgery, University of Calgary, Foothills Medical Centre, Calgary, Alta. (Blackmore, Dixon, MacLean, Ball); and the Department of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alta. (Tanyingo, Kaplan).



References

1. Addiss DG, Shaffer N, Fowler BS, et al. The epidemiology of appen-dicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910-25.

2. McBurney C. The incision made in the abdominal wall in cases of appendicitis, with a description of a new method of operating. Ann Surg 1894;20:38-43.

3. Semm K. Endoscopic appendectomy. Endoscopy 1983;15:59-64. 4. Sauerland S, Jaschinski T, Neugebauer EA. Laparoscopic versus

open surgery for suspected appendicitis. Cochrane Database Syst Rev 2010 Oct 6;(10)(10):CD001546.

5. Masoomi H, Mills S, Dolich MO, et al. Comparison of outcomes of lap-aroscopic versus open appendectomy in adults: data from the nationwide inpatient sample (NIS), 2006-2008. J Gastrointest Surg 2011;15:2226-31.

open-ball.indd 432 2015-11-10 10:01 AM

The Canadian Journal of Surgery is pleased to accept career/classi�ed advertisements. The deadline is 1 month before issue date.

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