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Laparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks.This project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods.Twenty-seven participants (13 ES, 14 NS, median age 34 years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563-648] vs 323 [130-464], p value 0.00036) and GOALS scores (14 [13-16] vs 10 [8-12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959-1010] vs 785 [626-856], p value 0.00009) and GOALS scores (16 [12-17] vs 12.5 [8.25-15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24-26] vs 17 [14-20], p value 0.0016 and CS 30 [27-32] vs 22[17.2-25.8], p value 0.00061).In conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Summary Postoperative occurrence of pneumonia can increase lengths of stay, risk of morbidity and death and health care costs. At Toronto General Hospital, we identified a high incidence of postoperative pneumonia in patients undergoing hepatectomy and Whipple procedures in 2016. To reduce the incidence of postoperative pneumonia, we implemented an evidence-based bundle approach in 2017. The bundle included the following components: oral care, incentive spirometry, coughing and deep breathing, physical activity, elevation of the head of the bed, and patient and family education. In addition to the bundle components, we provided staff education and created patient education and monitoring tools to ensure competency and compliance with the bundle components. Data collected as part of the National Surgical Quality Improvement Program were reviewed to monitor progress. In this article, we discuss our approach, aimed to reduce the incidence of postoperative pneumonia and associated health care costs in the general surgery population.

Background Obesity and type 2 diabetes can be associated with poor oral health. This can be because of hyposalivation leading to chronic oral inflammation (OI) and periodontal disease. Objective To assess the prevalence of hyposalivation and OI in individuals undergoing Roux-en-Y gastric bypass (RYGB) and determine the relationship with metabolic and anthropometric parameters before and after RYGB. Setting University hospital in Canada. Methods This was a cross-sectional and prospective cohort study of 59 patients undergoing RYGB from September 2015 to December 2019. Anthropometric, biochemical, and oral measurements were taken before surgery and 1 and 6 months post RYGB. Oral parameters included salivary flow rate and neutrophil count as marker of OI. Results Fifty-nine patients were enrolled with 29 completing this study. At baseline, the median age was 47 years and body mass index was 46.5 kg/m2, 52 (88.1%) were female and 14 individuals (23.7%) had type 2 diabetes; 54.2% (n = 32) of patients had hyposalivation and 13.6% (n = 8) had high neutrophil count. Patients with hyposalivation had significantly higher fasting glucose (5.7 mmol/L) compared with those without hyposalivation (5.2 mmol/L) but no difference was found between high versus low neutrophil count. At 6 months post RYGB, all variables except oral neutrophil count significantly improved. Hyposalivation persisted in 7 (24%) individuals. Conclusions In our bariatric patients, more than half the patients had hyposalivation before RYGB and this was associated with higher fasting glucose. Hyposalivation improved post RYGB in parallel with improvements in metabolic parameters but there was no change in OI. Increased salivation may reduce the risk of periodontal disease.

Context.— Laparoscopic sleeve gastrectomy (LSG) has quickly become the bariatric surgical procedure of choice for patients with obesity who have failed medical management. Laparoscopic sleeve gastrectomy results in a gastric remnant that is routinely subject to pathologic examination. Objective.— To perform a histologic and cost-benefit analysis of gastric remnants post-LSG. Design.— All LSG cases performed at University Health Network, Toronto, Ontario, Canada, between 2010 and 2019 were reviewed. Specimens that underwent routine histopathologic assessment and ancillary immunohistochemical analysis were analyzed. Baseline patient characteristics and surgical outcomes were obtained from our internal database. The total cost of specimen gross preparation, examination, sampling, and producing and reporting a hematoxylin-eosin slide was calculated. Results.— A total of 572 patients underwent LSG during the study period and had their specimens examined histologically. A mean of 4.87 blocks generating 4 hematoxylin-eosin slides was produced. The most common histologic findings reported in LSG specimens ranged from no pathologic abnormalities identified together with proton pump inhibitor–related change. A minority of cases demonstrated clinically actionable histologic findings, of which Helicobacter pylori infection was the most common. The total cost for the complete pathologic analysis of these cases amounted to CaD $66 383.10 (US $47 080.21) with a mean of CaD $116.05 (US $82.40) per case. A total of CaD $62 622.75 (US $44 413.30) was spent on full examination of cases that had no further postoperative clinical impact. Conclusions.— There is a broad spectrum of pathologic findings in LSG specimens, ranging from clinically nonactionable to more clinically actionable. The vast majority of histologic findings had no clinical impact, with only a minority of cases being clinically significant. This study therefore recommends that LSG specimens be subject to gross pathologic examination in the vast majority of cases. However, sections should be submitted for microscopic analysis if grossly evident lesions are present and if there is a clinical/known history of clinically actionable findings.

Background Improving the quality of care for patients who return home after a hospital stay is an international priority; however, few jurisdictions have engaged broadly with patients and caregivers to understand what most affects their experience transitioning home. We performed Ontario-wide group concept mapping, beginning with a brainstorming phase, to understand patient and caregiver priorities in the transition. Methods We used group concept mapping to engage patients and caregivers who had lived experience transitioning from hospital to home in Ontario in the previous 3 years. We report on the first phase, brainstorming, conducted over 10 weeks beginning Jan. 11, 2018 via an online survey or facilitated group discussion. Participants responded to a single focal prompt: "When leaving the hospital for home, some thing(s) that affected the experience were: ____." The study team identified recurrent concepts and overarching themes. Patients and caregivers informed the study design, recruitment and data interpretation. Results In all, 665 people (263 patients [39.5%], 352 caregivers [52.9%] and 50 people who were both patient and caregiver [7.5%]) participated in brainstorming online, and 71 people participated in 1 of 8 group discussions. Participants identified 6 key areas affecting their experience of transition from hospital to home: home and community care, the discharge process, medical follow-up after discharge, medications, patient and caregiver education, and the kindness and caring of the health care team in hospital. Most notable were challenges with the timeliness, sufficiency, reliability and consistency of publicly funded home care services. Interpretation Patients and caregivers from across Ontario noted a range of issues affecting their experience transitioning from hospital to home, particularly the quality and sufficiency of publicly funded home care. Our findings will be used to inform a provincial quality standard on the transition from hospital to home.

Laparoscopic sleeve gastrectomy (LSG) represents one of the most commonly performed bariatric procedures and, in contrast to the Roux-en-Y gastric bypass, produces a specimen for pathologic examination. This study aims to describe unexpected histopathological findings in order to better define preoperative management of patients undergoing LSG. All LSG cases performed at an academic center in Toronto, Ontario between 2010 and 2017 were reviewed. All specimens underwent histopathological assessment, while those with findings suspicious for neoplasia or the presence of Helicobacter pylori underwent additional immunohistochemical stainings. Baseline patient characteristics and surgical outcomes were obtained from our internal database. A total of 222 patients underwent LSG during the study period and had their specimens examined histologically. Among them, 22.5% underwent preoperative endoscopy. The most common histopathological diagnosis was no abnormal findings (50.9%) followed by gastritis (25.7%). Abnormal findings warranting a change in postoperative management or follow-up were discovered in 8.6% of specimens and included H. pylori infection, intestinal metaplasia, malignancy, and atrophic gastritis. Only 4.7% of all patients had not undergone preoperative endoscopy and had truly unexpected findings. No significant association was found between abnormal findings and age, sex, or baseline body mass index (BMI). Although a majority of patients had a gastric specimen within normal limits, 8.6% had findings requiring a change in postoperative management. This rate dropped to 4.7% when patients whose diagnoses were known preoperatively were excluded. Our findings suggest that further research is needed to better define the role of preoperative endoscopy to potentially reduce the number of unexpected findings following LSG.

The fundamentals of laparoscopic surgery (FLS) program is a simulation-based training program designed to teach and assess the basic skills necessary for laparoscopic surgery. Preliminary work has demonstrated the feasibility of using Skype™ as a telesimulation modality in reliably scoring the exam for remote centers. Google Glass (GG) (Mountain View, California) is referred to as a wearable computer containing a heads-up display and front-facing camera allowing point-of-view video transmission. The objective of this study was to evaluate the feasibility of GG in scoring the technical skills component of the FLS exam. Twenty-eight participants were asked to complete the peg transfer and intracorporeal knot tasks of FLS using both GG and Skype™ setups. GG employed a third-party HIPAA-compliant video software (Pristine; Austin, TX) for video transmission. Participants were alternated between setups and evaluated by onsite and remote proctors. Times and errors were recorded by both proctors. Interrater reliability of their FLS scores was compared using Intraclass Correlation Coefficients (ICCs). GG experience was evaluated based on participant survey responses using a 5-point Likert scale. Interrater reliability for GG demonstrated a statistically significant correlation between onsite (OP) and remote (RP) proctors with ICCs of 0.985 (95% Confidence Interval [CI], 0.969–0.993) and 0.997 (95% CI 0.993–0.998), respectively, for peg and suture tasks. Skype™ demonstrated ICCs of 1.0 (95% CI 1.0–1.0). Average Likert scale responses found GG to be distracting (2.71), obstructive of the view (2.79), and a limitation to task execution (2.75). Overall, there was no statistical difference in scores between GG and Skype™ setups for either the peg (t = 1.446, p = 0.154) or suture task (t = − 0.710, p = 0.480), only 1 participant found the use of GG superior to Skype™. Our findings suggest that although GG are feasible in remote assessment of FLS with strong interrater reliability (ICC > 0.95), Skype™ was the preferred modality.

The use of a flexible optical bronchoscopic (FOB) for intubation is an essential airway management skill.Our primary objective was to compare the effects of simulator training (ORSIM high-fidelity simulator) with no simulation training on the performance of FOB intubation in anaesthetised patients.Randomised controlled trial.Single-centre tertiary hospital; trial conducted between April 2015 to May 2016.Medical students, anaesthesia assistants and anaesthesia residents with experience of less than five FOB intubations from whom informed consent was obtained.Students, anaesthesia assistants and anaesthesia residents viewed a didactic presentation before performing an initial FOB intubation in an anaesthetised patient. Intubations were recorded and evaluated using the Global Rating Scale (GRS) and checklist scores. Subsequently, participants were randomised to control group (Group CON) and had no simulation training, or to a simulation group (Group SIM) and underwent 60 min of simulation practice. Within a week, participants performed a second FOB intubation and were similarly evaluated.Pretraining and posttraining intubation time, GRS and checklist scores.Baseline characteristics were similar between groups. In Group SIM, there was significant improvement between pre and posttraining GRS [22.9 ± 8.1 vs. 28.2 ± 7.3, mean difference (95% CI) 5.3 (0.3 to 10.3), P = 0.04], and intubation time [177.6 ± 77.6 vs. 119.3 ± 52.2 s, mean difference (95% CI) -58.4 (-100.3 to -16.5) s, P = 0.01]. There was no difference in Group CON, between pre and posttraining intubation time, GRS or checklist.We conclude, posttraining performance of FOB intubation, as measured by intubation time and GRS, improved in Group SIM, while it was unchanged in the Group CON. The ORSIM simulator may be a useful adjunct in acquiring FOB intubation skills.ClinicalTrials.gov ID: NCT02699242.

Background Obesity affects individuals worldwide and is currently the 5 th leading cause of death according to the WHO. Bariatric surgery is an effective strategy that produces durable long-term weight loss. There is a bidirectional interplay between mental health and obesity; with higher depression and anxiety in the obese population as well as significant effects on weight loss for people with mental health disorders. Objective Our cross-sectional study aimed to examine psychosocial predictors of cognition for the pre-operative bariatric surgery population and its effect on work productivity. Methods Demographic data, perceived cognitive deficits (PDQ-5), depression scale (PHQ-9), anxiety (GAD-7), Quality of life (SF36) and work impairment (LEAPS) was collected from 302 pre-operative bariatric surgery candidates at their initial assessment. Multiple regression was conducted with perceived cognitive deficits as the dependent variable. A secondary analysis was done controlling for anxiety and depression. Results Variables that were significantly associated with perceived cognition were anxiety, depression, work productivity and overall mental health quality of life. Perceived cognition was also significantly associated with work impairment independent of mood symptoms. Discussion Anxiety and depression are prevalent in the pre-operative bariatric surgery population, significantly affecting cognition, and should be routinely screened. Work performance was also affected by cognition in our population but the link between obesity and cognition needs to be further explored. Conclusions We identified a significant association between perceived cognition and psychosocial factors in pre-operative bariatric surgery candidates. Further studies will be needed to better explore obesity and its impact on cognition.

Background Perioperative patient education and engagement are critical components of care in patients undergoing bariatric surgery, given the short length of stay and the requirements to adhere to various instructions. The use of patient engagement mobile technology may promote adherence to perioperative protocols and improve care by potentially identifying complications earlier and reducing associated health care costs. Materials and methods We introduced a mobile app that provides bariatric patients with access to educational materials and the ability to report on their symptoms. Using the data from the app and linking the data to patient outcomes collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, we examined the effects of the app on readmission, length of stay, visits to the emergency department (ED), and patient satisfaction. Results A total of 505 patients were enrolled in the app between July 2017 and March 2019. Among them, 396 patients who met the inclusion criteria for the study were compared with 458 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who were not enrolled in the app for the same study period. While the use of the app was not associated with the rates of prolonged length of stay, ED visits, and readmission, patients who completed a survey at 30 d after discharge reported that the app helped them avoid phone calls to the hospital (48.5%) and ED visits (13.0%). Furthermore, 94.8% of these patients reported that they would recommend the app to other patients undergoing the same surgery. Conclusions Additional features, such as the ability for patients to directly communicate with the health care providers within the app, may be effective in decreasing unnecessary health care utilization.

Marginal ulcer formation is a known complication following RYGB. While most respond to medical therapy, many patients have recurrent or chronic MU. Although non-steroidal anti-inflammatory drug (NSAID) use, smoking and Helicobacter pylori infection are known risk factors of MU, little is known about what increases the likelihood of developing recalcitrant ulcers. The objective of this study is to identify risk factors for marginal ulcer (MU) formation, including recalcitrant ulcers requiring surgical revision, and to define the incidence and outcomes of revisional surgery.All patients who underwent RYGB between 2011 and 2017 at a high-volume academic center were included. Patients with a postoperative diagnosis of MU were identified from the institution's bariatric database. Patient characteristics, operative data and surgical outcomes were analyzed using data collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and the Ontario Bariatric Registry.A total of 2830 RYGB were performed during the study period. The incidence of MU was 6.9% with 1% of patients requiring revisional surgery for a recalcitrant ulcer. Patients with a history of smoking (HR 5.03), immunosuppression (HR 4.60) and preoperative NSAID use (HR 3.11) were significantly more likely to develop a MU requiring surgical revision. Patients undergoing revision reported resolution of their symptoms in only 36% of cases with 57% developing a recurrent ulcer.Patients with a history of smoking and use of immunosuppressive medication were at significantly higher risk of developing MU that failed medical therapy. Additional evidence is needed to inform perioperative management of bariatric patients.

BackgroundBariatric surgical procedures are employed when there is a failure of lifestyle modification in arresting obesity. Laparoscopic sleeve gastrectomy (LSG) is quickly becoming the bariatric surgical procedure of choice. LSG results in a gastric remnant that is subject to pathological examination. The objective of this paper is to review the literature in regard to histological findings identified in gastric remnants post-LSG and identify the most pertinent histological findings.Materials and methodsA literature search was performed to identify relevant case series. Data gathered from relevant case series then underwent statistical analysis.ResultsThe most common histological findings in an LSG specimen were clinically indolent findings such as no pathological abnormalities identified followed by non-specific gastritis. A minority of cases demonstrated clinically actionable findings for which Helicobacter pylori represented the majority of these findings.ConclusionThere is a broad spectrum of pathological findings in LSG specimens, ranging from clinically indolent to clinically actionable. The most common histological findings are clinically indolent and only a small portion are of clinical significance and, hence, actionable.

Bariatric surgery is an effective weight loss tool that results in sustained weight loss, improvement in obesity-related comorbidities, and positive psychosocial outcomes. However, bariatric procedures also present with risks, as surgical complications are not uncommon.This study aims to better understand the effect of postoperative complications from bariatric surgeries on patients' psychosocial well-being.Surgical data on postoperative complications were matched with results from self-administered psychosocial questionnaires. Depression, anxiety, and quality of life (QOL) were assessed preoperatively, and at 1-year postoperatively.A total of 365 patients were included. Overall, the complication rate was 15.3% (n = 56), with 31 (8.5%) patients experiencing complications within 30 days of surgery, and 25 (6.8%) experiencing late complications. All patients achieved significant weight loss at 1-year postoperatively. Patients with uncomplicated recoveries showed significant improvement in depression (P0.001), anxiety (P0.001), mental QOL (P0.001), and physical QOL (P0.001) at 1-year postsurgery. Patients who experienced postoperative complications showed significant improvement in depression (P0.001), anxiety (P = 0.04) and physical QOL (P0.001), but not in mental QOL (P = 0.210). Despite improved psychosocial outcomes from baseline, patients experiencing complications showed higher postoperative depression scores (P0.01) and lower physical QOL (P0.01) than patients without complication. Comparison between those with early and late complications did not show significant difference in outcomes.Complications following bariatric surgery can hinder improvements in patient's psychological well-being and QOL. Bariatric centers should provide more support for patients who have experienced complications.

In obese individuals undergoing Roux-en-Y gastric bypass (RYGB), nonalcoholic fatty liver disease (NAFLD) is seen in 75% to 100% of cases. This improves postsurgery, but some patients continue to have persistent NAFLD.The purpose of this study was to determine the factors associated with persistent NAFLD at 12 months post-RYGB.University Hospital, Canada, bariatric clinic.This is a prospective cohort study of 42 patients who underwent RYGB. Liver biopsy, biochemical and clinical parameters were collected pre- and 12 months post-RYGB. Based on histology at 12 months, patients were separated in 2 groups, normal liver (NL) and persistent NAFLD.At baseline, NAFLD was diagnosed in 85.7% of patients and at 12 months post-RYGB, NAFLD was present in 19.1% of patients. Patients who had an NL at baseline remained with NL. RYGB resulted in significant decreases in body mass index, waist circumference, blood pressure, aspartate aminotransferase, alanine aminotransferase, fasting glucose and insulin, glycated hemoglobin, and triglycerides and significant increases in high-density lipoprotein cholesterol. Changes were similar in both groups except for waist circumference, which showed lower changes in those with persistent NAFLD. These patients also had significantly higher (P.05) fasting glucose and insulin with a higher proportion of patients having insulin resistance compared with those with NL.RYGB resulted in significant improvements in liver histology, biochemical, and clinical parameters. However, despite similar weight loss, persistent NAFLD was associated with less improvement in waist circumference and worse glycemic control.

Laparoscopic adjustable gastric band (LAGB) placement remains a common bariatric procedure. While LAGB procedure is performed within private clinics in most Canadian provinces, public health care is often utilized for LAGB-related reoperations. We identified 642 gastric band removal procedures performed in Ontario from 2011 to 2014 using population-level administrative data. The number of procedures performed increased annually from 101 in 2011 to 220 in 2014. Notably, 54.7% of the patients required laparotomy, and 17.6% of patients underwent a subsequent bariatric surgery. Our findings demonstrated that LAGB placement in private clinics resulted in a large number of band removal procedures performed within the public system. This represents a significant public health concern that may result in significant health care utilization and patient morbidity.

The purpose of this study was to evaluate the relationship between patient, clinical and laboratory characteristics, and bleeding after bariatric surgery. A retrospective chart review was performed for all patients, who underwent a laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy at our institution between March 2012 and May 2014. In total, 788 patients were included in this study. Seventeen patients had postoperative bleeding. The demographics, comorbidities, and preoperative medications were similar between the groups. Mean postoperative hemoglobin in the bleeding group was significantly lower (94 vs. 126; P

BackgroundWith greater transparency in health system reporting and increased reliance on patient-centred outcomes, patient satisfaction has become a priority in delivering quality care. We sought to explore the relationship between patient satisfaction and short-term outcomes in patients undergoing general surgical procedures.MethodsSatisfaction surveys were distributed to patients following discharge from the general surgery service at an academic hospital between June 2012 and March 2015. Short-term clinical outcomes were obtained from the American College of Surgeons National Surgical Quality Improvement Program database. Patients rated their level of satisfaction on a 5-point Likert scale, and ordered logistic regression model was used to determine predictors of high patient satisfaction.Results757 patient satisfaction surveys were completed. The mean age of patients surveyed was 52.2 years; 60.0% of patients were female. The majority of patients underwent a laparoscopic procedure (85.9%) and were admitted as inpatients following surgery (72%). 91.5% of patients rated satisfaction of 4–5, and 95.0% said they would recommend the service. The odds of overall satisfaction were lower in patients who had complications (OR: 0.52, 95% CI 0.31 to 0.87) and 30-day readmission (OR: 0.35, 95% CI 0.17 to 0.70). Having elective surgery was associated with higher odds of satisfaction (OR: 1.62, 95% CI 1.07 to 2.47).ConclusionsWe found a significant association between patient satisfaction and both 30-day readmission and the occurrence of postoperative surgical complications. Given this association, further study is warranted to evaluate patient satisfaction as a healthcare quality indicator.

Non-alcoholic fatty liver disease (NAFLD) affects 75 to 100% of the patients undergoing bariatric surgery (BSx), with non-alcoholic steatohepatitis (NASH) being present in 24 to 98% of the patients. We do not know whether these rates were before or after a very low calorie diet (VLCD) often prescribed before laparoscopic BSx and what is the prevalence of NAFLD post-VLCD. The purpose of this study is to determine the prevalence of simple steatosis (SS) and NASH in obese individuals undergoing BSx post-VLCD and assess biochemical markers pre- and post-VLCD in a subgroup of patients. One hundred and thirty-nine patients undergoing BSx at a single Canadian bariatric program had biochemical and clinical variables collected pre-VLCD. In 21 patients, biochemical measurements were repeated post-VLCD. During BSx, a wedged liver biopsy was performed in all patients and histology was reported as normal liver (NL), SS, or NASH. NAFLD was diagnosed in 76.3% of the BSx patients with 61.9% having SS and 14.4% having NASH; 23.7% had NL. Those with NASH had significantly higher (p < 0.05) pre-VLCD ALT, AST, insulin resistance, and proportion of individuals with diabetes compared to those with NL. Overall, VLCD resulted in significant decreases in BMI, ALP, fasting glucose and insulin, HbA1c, total cholesterol, HDL and LDL cholesterol, and significant increases in AST and ALT. Changes were similar between groups. Post-VLCD, the prevalence of NAFLD and NASH was lower compared to published reports, with almost 25% of the patients having a NL. With VLCD, metabolic and clinical changes were similar between the three groups suggesting that pre-VLCD factors may affect liver histology.

The Fundamentals of Laparoscopic Surgery® (FLS) certification exam assesses both cognitive and manual skills, and has been administered for over a decade. The purpose of this study is to report results over the past 9 years of testing in order to identify trends over time and evaluate the need to update scoring practices. This is a quality initiative of the SAGES FLS committee. A representative sample of FLS exam data from 2008 to 2016 was analyzed. The de-identified data included demographics and scores for the cognitive and manual tests. Standard descriptive statistics were used to compare trends over the years, training levels, and to assess the pass/fail rate. A total of 7232 FLS tests were analyzed [64% male, 6.4% junior (postgraduate year—PGY1–2), 84% senior (PGY3–5), 2.8% fellows (PGY6), and 6.7% attending surgeons (PGY7)]. Specialties included 93% general surgery (GS), 6.2% gynecology, and 0.9% urology. The Pearson correlation between cognitive and manual scores was 0.09. For the cognitive exam, there was an increase in scores over the years, and the most junior residents scored the lowest. For the manual skills, there were marginal differences in scores over the years, and junior residents scored the highest. The odds ratio of PGY3+ passing was 1.8 (CI 1.2–2.8) times higher than that of a PGY1–2. The internal consistency between tasks on the manual skills exam was 0.73. If any one of the tasks was removed, the Cronbach’s alpha dropped to between 0.65 and 0.71, depending on the task being removed. The cognitive and manual components of FLS test different aspects of laparoscopy and demonstrate evidence for reliability and validity. More experienced trainees have a higher likelihood of passing the exam and tend to perform better on the cognitive skills. Each component of the manual skills contributes to the exam and should continue to be part of the test.

Enhanced Recovery After Surgery (ERAS) guidelines have been widely promoted and supported largely due to several studies showing decreased post-operative complications and length of stay. The objective of this study was to review the emergency room (ER) visits and readmission rates and reasons for both in patients who were part of the Implementation of an Enhanced Recovery After Surgery (iERAS) program for colorectal surgery. All patients having elective colorectal surgery at 15 academic hospitals were enrolled in the iERAS program. All patients were prospectively followed until 30 days post-discharge. Data were analyzed using descriptive statistics and multivariable analysis. A total of 2876 patients (48% female; mean 60 years old) were enrolled. Cancer was the most frequent indication (68.2%) for surgery. Overall, the median length of stay (LOS) was 5 days. Post-discharge, 359 (11.6%) of patients had a visit to the ER not requiring admission. The most common reasons for visiting the ER were surgical site infections (SSI) (34.5%), other wound complications (10.0%), and urinary tract infections (UTI) (8.6%). In addition, a smaller proportion of patients, 260 (8.2%) required readmission. The most common reasons for readmission were ileus and nausea/vomiting (26.1%), intra-abdominal abscess (23.9%), and SSI (11.5%). Patient and disease factors associated with ER visits, on multivariable analysis, included extremes of BMI (RR 1.02, 95%CI 1.01–1.04, p = 0.002), rectal surgery versus colon surgery (RR 1.34, 95%CI 1.14–1.58, p

The objective of the study was to determine whether compliance with Enhanced Recovery after Surgery (ERAS) urinary catheter recommendations is associated with decreased urinary tract infections (UTI) and length of stay (LOS). Patients having colorectal surgery at 15 academic hospitals were included. Patient and outcome data were collected prospectively. The guideline recommends that urinary catheters following colonic and rectal procedures should be removed at or before 24 and 72 h, respectively. Two thousand nine hundred and twenty-seven patients (1397 females and 1522 males; mean age 60.3 years) were enrolled. Small bowel or colonic procedures were performed in 1897 (64.9%) and rectal procedures in 1030 (35.2%) patients. Overall, 53.2% of patients had their catheter removed in compliance with the guidelines (44.3% after colonic resections and 69.5% after rectal resections). Following colonic operations, 0.8% of patients who were guideline compliant had a UTI compared to 4.1% non-compliant patients (RR 0.20, 95% CI 0.07–0.58; p = 0.003). Following rectal operations, 3.5% of patients who were guideline compliant had a UTI compared to 9.6% of patients who were non-compliant (RR 0.37, 95% CI 0.20–0.68; p = 0.001). Median LOS was decreased in compliant patients: 4 vs 5 days following colonic procedures (RR 0.73, 95% CI 0.66–0.82; p

BACKGROUND: The relative educational benefits of virtual reality (VR) and physical simulation models for endoscopic third ventriculostomy (ETV) have not been evaluated "head to head."OBJECTIVE: To compare and identify the relative utility of a physical and VR ETV simulation model for use in neurosurgical training.METHODS: Twenty-three neurosurgical residents and 3 fellows performed an ETV on both a physical and VR simulation model. Trainees rated the models using 5-point Likert scales evaluating the domains of anatomy, instrument handling, procedural content, and the overall fidelity of the simulation. Paired t tests were performed for each domain's mean overall score and individual items.RESULTS: The VR model has relative benefits compared with the physical model with respect to realistic representation of intraventricular anatomy at the foramen of Monro (4.5, standard deviation [SD] = 0.7 vs 4.1, SD = 0.6; P = .04) and the third ventricle floor (4.4, SD = 0.6 vs 4.0, SD = 0.9; P = .03), although the overall anatomy score was similar (4.2, SD = 0.6 vs 4.0, SD = 0.6; P = .11). For overall instrument handling and procedural content, the physical simulator outperformed the VR model (3.7, SD = 0.8 vs 4.5; SD = 0.5, P CONCLUSION: Simulation model selection should be based on educational objectives. Training focused on learning anatomy or decision-making for anatomic cues may be aided with the VR simulation model. A focus on developing manual dexterity and technical skills using endoscopic equipment in the operating room may be better learned on the physical simulation model.

INTRODUCTION Practice data can inform the selection of educational strategies; however, it is not widely used, even when available. This study's purpose was to determine factors that influence physician engagement with practice data to advance competence and drive practice change. METHODS A practice-based, pan-Canadian survey was administered to three physician subspecialties: psychiatrists (Psy), radiation oncologists (RO), and general surgeons (GS). The survey was distributed through national specialty society membership lists. The survey assessed factors that influence the use of data for practice improvement and orientation to lifelong learning, using the Jefferson Scale of Physician Lifelong Learning (JeffSPLL). Linear regression was used to model the relationship between the outcome variable frequency of data use and independent predictors of continuous learning to improving practice. RESULTS A total of 305 practicing physicians (Psy = 203, RO = 53, GS = 49) participated in this study. Most respondents used data for practice improvement (n = 177, 61.7%; Psy = 115, 40.1%; RO = 35; 12.2%; GS = 27, 9.4%) and had high orientation to lifelong learning (JeffSPLL mean scores: Psy = 47.4; RO = 43.5; GS = 45.1; Max = 56). Linear regression analysis identified significant predictors of data use in practice being: frequency of assessing learning needs, helpfulness of data to improve practice, and frequency to develop learning plans. Together, these predictors explained 42.9% of the variance in physicians' orientation toward integrating accessible data into practice (R = 0.426, P < .001). DISCUSSION This study demonstrates an association between practice data use and perceived data utility, reflection on learning needs and learning plan development. Implications for this work include process development for data-informed action planning for practice improvement for physicians.

The intestinal immune system is emerging as an important contributor to obesity-related insulin resistance, but the role of intestinal B cells in this context is unclear. Here, we show that high fat diet (HFD) feeding alters intestinal IgA+ immune cells and that IgA is a critical immune regulator of glucose homeostasis. Obese mice have fewer IgA+ immune cells and less secretory IgA and IgA-promoting immune mediators. HFD-fed IgA-deficient mice have dysfunctional glucose metabolism, a phenotype that can be recapitulated by adoptive transfer of intestinal-associated pan-B cells. Mechanistically, IgA is a crucial link that controls intestinal and adipose tissue inflammation, intestinal permeability, microbial encroachment and the composition of the intestinal microbiome during HFD. Current glucose-lowering therapies, including metformin, affect intestinal-related IgA+ B cell populations in mice, while bariatric surgery regimen alters the level of fecal secretory IgA in humans. These findings identify intestinal IgA+ immune cells as mucosal mediators of whole-body glucose regulation in diet-induced metabolic disease., The effect of diet-induced obesity on intestinal B cell populations is not well understood despite emerging evidence of a critical role for the intestinal immune system in contributing to insulin resistance. Here, the authors show important functions of IgA in regulating metabolic disease and for intestinal immunity in modulating systemic glucose metabolism.

BackgroundPatients and caregivers often face significant challenges when they are discharged home from hospital. We sought to understand what influenced patient and caregiver experience in the transition from hospital to home and which of these aspects they prioritised for health system improvement.MethodsWe conducted group concept mapping over 11 months with patients—and their caregivers—who were admitted to a hospital overnight in the last 3 years in Ontario, Canada and discharged home. Home included supportive housing, shelters and long-term care. Participants responded to a single focal prompt about what affected their experience during the transition. We summarised responses in unique statements. We then recruited participants to rate each statement on a five-point scale on whether addressing this gap should be a priority for the health system. The provincial quality agency recruited participants in partnership with patient, community and healthcare organisations. Participation was online, in-person or virtual.Results736 participants provided 2704 responses to the focal prompt. Unique concepts were summarised in 52 statements that were then rated by 271 participants. Participants rated the following three statements most highly as a gap that should be a priority for the health system to address (in rank order): ‘Not enough publicly funded home care services to meet the need’, ‘Home care support is not in place when arriving home from hospital’ and ‘Having to advocate to get enough home care’. The top priority was consistent across multiple subgroups.ConclusionsIn a country with universal health insurance, patients and caregivers from diverse backgrounds consistently prioritised insufficient public coverage for home care services as a gap the health system should address to improve the transition from hospital to home.

Physical activity (PA) helps sustain weight loss and may also provide psychological benefits in patients undergoing bariatric surgery. Using a set of questionnaires, we demonstrated that bariatric patients with increased level of PA at 1-year follow-up had better psychosocial outcomes including depressive symptoms and mental health-related quality of life compared with those who had reduced or unchanged level of PA. Our findings indicate the benefit of incorporating PA in the postoperative care for bariatric patients. Novelty Postoperative behavioural change in terms of physical activity improves psychosocial health in patients undergoing bariatric surgery.

Health literacy represents the degree to which patients can understand and act on health information. The relevance of health literacy to health care delivery, outcomes, and overall surgical care is unambiguous. This study aimed (1) to determine the prevalence of limited health literacy in patients diagnosed with Dupuytren's contracture and (2) to identify independent predictors of limited health literacy.This cross-sectional study included patients with Dupuytren's disease and with self-reported English fluency. The Newest Vital Sign, a rapid, validated, and reliable screening tool, was selected to measure health literacy. An exploratory multivariable logistic regression model was used to identify possible predictors of limited health literacy.A total of 185 patients met eligibility criteria and were included. From those, 82 (44 percent) were found to have limited health literacy, defined as a score of 3 or less on the Newest Vital Sign. The domain of prose literacy was most highly scored compared to numeracy and document literacy. Lower household income was associated with a 4.7-fold increase in the odds of having limited health literacy. Being an immigrant also increased the odds of having limited health literacy by a factor of 3.6. Sensitivity analyses and subgroup analyses (based on education, maternal language, and immigration status) corroborated these independent predictor findings.Limited health literacy is common among patients with Dupuytren's contracture. System level changes are necessary such as the access and integration to clinical care of universal measures of support to promote productive patient-surgeon interactions.

Colonoscopy for colorectal cancer (CRC) has a localization error rate as high as 21 %. Such errors can have substantial clinical consequences, particularly in laparoscopic surgery. The primary objective of this study was to compare accuracy of tumor localization at initial endoscopy performed by either the operating surgeon or non-operating referring endoscopist. All patients who underwent surgical resection for CRC at a large tertiary academic hospital between January 2006 and August 2014 were identified. The exposure of interest was the initial endoscopist: (1) surgeon who also performed the definitive operation (operating surgeon group); and (2) referring gastroenterologist or general surgeon (referring endoscopist group). The outcome measure was localization error, defined as a difference in at least one anatomic segment between initial endoscopy and final operative location. Multivariate logistic regression was used to explore the association between localization error rate and the initial endoscopist. A total of 557 patients were included in the study; 81 patients in the operating surgeon cohort and 476 patients in the referring endoscopist cohort. Initial diagnostic colonoscopy performed by the operating surgeon compared to referring endoscopist demonstrated statistically significant lower intraoperative localization error rate (1.2 vs. 9.0 %, P = 0.016); shorter mean time from endoscopy to surgery (52.3 vs. 76.4 days, P = 0.015); higher tattoo localization rate (32.1 vs. 21.0 %, P = 0.027); and lower preoperative repeat endoscopy rate (8.6 vs. 40.8 %, P

Vitamin supplementation in bariatric aftercare is essential to prevent nutrient deficiencies; however, rates of vitamin adherence have been as low as 30 % 6 months post-surgery. Preliminary literature suggests non-adherence to prescribed treatments can be linked to demographic and psychological factors. We aimed to determine the relationship between these factors to vitamin adherence in post-bariatric surgery patients. A total of 92 bariatric patients were assessed 6 months post-surgery. Patients were administered a questionnaire collecting demographic information, psychological scores, and self-reported adherence. Nutrient deficiencies were analyzed through serum vitamin levels measured 3 and 6 months after surgery. Wilcoxon rank-sum and chi-square tests were used for analysis. Non-adherence was associated with male sex and full-time employment (p = 0.027, p = 0.015). There were no differences with respect to living situation, education level, or relationship type. Non-adherent patients did not have significantly higher scores for generalized anxiety, depressive symptoms, or avoidant behaviors. However, non-adherent patients displayed greater attachment anxiety than their adherent counterparts (p = 0.0186). Non-adherence was also associated with lower vitamin B12 levels 6 months post-surgery (p = 0.001). Male gender and full-time work have previously been shown to be associated with non-adherence. This is the first study to demonstrate that attachment anxiety is associated with poor multivitamin adherence in the post-surgical bariatric population. This result is concordant with recent literature that has demonstrated attachment anxiety is associated with poor adherence to dietary recommendations in bariatric patients 6 months postoperatively. Presurgical screening for attachment anxiety could facilitate early interventions to promote better bariatric aftercare in this group.

Colorectal cancer (CRC) is the third most commonly diagnosed cancer in Canada. In 2014, an estimated 24 300 individuals will have CRC diagnosed and an estimated 9300 will die of the disease.1 Colonoscopy is considered the gold standard for detection of CRC, with a specificity of 90.0% and a sensitivity of 95.0%.2 Over the past decade, the rise of minimally invasive surgical (MIS) techniques has made endoscopic lesion localization critical to surgical planning. However, little is known about the localization practices of gastroenterologists and general surgeons. Although colonoscopy demonstrates excellent detection rates for both malignancies and adenomas, its ability to provide precise localization information is less clear. In the literature, estimates of the error rate in tumour localization vary from as low as 4% to as high as 21%.3–10 These errors can have a dramatic impact on surgical management, especially in laparoscopic cases where the surgeon lacks the tactile ability to palpate the colon for the lesion. This may result in conversion from a laparoscopic to open approach, intraoperative colonoscopies and removal of incorrect segments of colon. To help surgical planning and prevent such complications, surgeons often perform repeat colonoscopy before CRC surgery to verify lesion location. In a recent study by Al Abbasi and colleagues,11 the repeat endoscopy rate at a large tertiary academic centre before CRC surgery was estimated to be up to 40.5%. Factors associated with preoperative repeat endoscopy by the operating surgeon were left-sided colonic neoplasms, planned laparoscopic resection and failure to tattoo the lesion on the initial colonoscopy.11 However, to our knowledge, no studies have assessed the perceptions of gastroenterologists toward repeat endoscopy and its indications. When a lesion is detected by colonoscopy, endoscopists have a myriad of localization techniques at their disposal. They include use of anatomic landmarks, distance from the anal verge, image capture if the lesion is near an identifiable landmark, hemoclips and tattooing. No formal protocols exist to guide endoscopists in choosing the appropriate localization technique, and little is known about current use of these practices as they relate to repeat endoscopy before CRC surgery. Localization based on anatomic landmarks is often reported in the vast majority of polypectomies;12 however, this technique has been associated with error rates as high as 21%.3–10 Less clear is the practice of colonoscopic image capture, with studies demonstrating varied utilization rates.12,13 Moreover, there is a paucity of literature assessing the use of hemoclips in colonoscopy. Tattoo localization is considered the most accurate localization technique, and lack of tattoo localization is the most cited reason for repeat endoscopy by the operating surgeon.11,14 Nevertheless, the rate of tattooing remains quite low — between 0% and 23%.15,16 Furthermore, while tattoo localization is often recommended for colonic lesions suspicious for malignancy,17 the use of tattooing in different clinical scenarios remains unclear. Given the limited evidence available on the localization practices of endoscopists, including the use of tattoo localization, the primary objective of our study was to identify the colonoscopic localization practices of gastroenterologists and to clarify the role of tattoo localization in this setting. The secondary objective was to assess the attitudes and perceptions of gastroenterologists toward repeat endoscopy and to compare their perceptions to those of general surgeons identified by a recent survey.

Extreme obesity (EO) (BMI >50 kg/m2) is frequently associated with neuropsychiatric disease (NPD). As both EO and NPD are heritable central nervous system disorders, we assessed the prevalence of protein-truncating variants (PTVs) and copy number variants (CNVs) in genes/regions previously implicated in NPD in adults with EO (n = 149) referred for weight loss/bariatric surgery. We also assessed the prevalence of CNVs in patients referred to University College London Hospital (UCLH) with EO (n = 218) and obesity (O) (BMI 35–50 kg/m2; n = 374) and a Swedish cohort of participants from the community with predominantly O (n = 161). The prevalence of variants was compared with control subjects in the Exome Aggregation Consortium/Genome Aggregation Database. In the discovery cohort (high NPD prevalence: 77%), the cumulative PTV/CNV allele frequency (AF) was 7.7% vs. 2.6% in control subjects (odds ratio [OR] 3.1 [95% CI 2–4.1]; P < 0.0001). In the UCLH EO cohort (intermediate NPD prevalence: 47%), CNV AF (1.8% vs. 0.9% in control subjects; OR 1.95 [95% CI 0.96–3.93]; P = 0.06) was lower than the discovery cohort. CNV AF was not increased in the UCLH O cohort (0.8%). No CNVs were identified in the Swedish cohort with no NPD. These findings suggest that PTV/CNVs, in genes/regions previously associated with NPD, may contribute to NPD in patients with EO.

The safety of emergent laparoscopic repair of incarcerated ventral hernias is not well established. The objective of this study was to determine if emergent laparoscopic repair of incarcerated ventral hernias is comparable to open repair with respect to short-term clinical outcomes. Patients undergoing emergency repair of an incarcerated ventral hernia with associated obstruction and/or gangrene were identified using the ACS-NSQIP 2012–2016 dataset. One-to-one coarsened exact matching (CEM) was conducted between patients undergoing laparoscopic and open repair. Matched cohorts were compared with respect to morbidity, mortality, readmission, reoperation, missed enterotomies, and length of stay. Missed enterotomy was defined as any re-operative procedure within 30 days that required resection of large or small bowel segments, based on CPT codes. Multivariate analysis was conducted to determine adjusted predictors of morbidity. A total of 1642 patients were identified after CEM. Laparoscopic compared to open repair was associated with a lower rate of 30-day wound-morbidity (OR 0.35, 95% CI 0.22–0.57, p

Adult extreme obesity (EO) is a growing health concern. The prevalence of known obesity associated co-morbidities namely cardio-metabolic and neuro-psychiatric disease in EO is not fully established. The contribution of pathogenic genetic variants, previously implicated in early childhood onset obesity, to adult EO is also not established.We undertook phenotypic and genetic analysis of adult patients with extreme obesity (EO, BMI 50). Specifically, we assessed the prevalence of eating disorders, cardio-metabolic, and neuro-psychiatric disease and the presence of pathogenic variants in known monogenic obesity genes.A total of 55 patients with EO from a single site bariatric surgery referral program were assessed for the presence of eating disorders, cardio-metabolic, and neuro-psychiatric disease. The 54 obese (O) patients with a BMI 50 from the same program were identified for phenotypic comparison. The 45 EO patients underwent whole exome sequencing to identify deleterious variants in known monogenic obesity genes.(1) Presence of eating disorders, cardio-metabolic, and neuro-psychiatric disease in EO compared to O. (2) Onset of obesity in the EO group. (3) Presence of deleterious variants in genes previously implicated in monogenic obesity in the EO group.The EO group had higher prevalence of lifetime neuro-psychiatric disease (67.3% vs. 37%, p = 0.001) and sleep apnea (74.6% vs. 51.9%, p = 0.01) but lower prevalence of type 2 diabetes (30.1% vs. 50%, p = 0.045) compared to O. There were no significant differences in binge eating, dyslipidemia, hypertension, and cardiac disease. In the EO group, we found previously unreported singleton variants in NTRK2 (pS667W, bio-informatically predicted to be deleterious) and BDNF (pE23K). No previously confirmed loss of function variants in monogenic obesity genes were found.Adults with EO have significantly increased prevalence of neuro-psychiatric disease and a possibly lower burden of type 2 diabetes compared to less obese patients. Known monogenic causes of obesity were not highly prevalent in this cohort. Further studies are warranted to confirm these preliminary findings.

Background An admission to hospital for acute illness can be difficult for patients and lead to high levels of anxiety. Patients are given a lot of information throughout their hospital stay and instructions at discharge to follow when they get home. For complex medical patients, the ability to retain, understand, and adhere to these instructions is a critical marker of a successful transition. This study was undertaken to explore factors impacting the ability of patients to understand and adhere to instructions. Methods A qualitative design of interviews with patients and caregivers was used. Participants were adult patients and caregivers with congestive heart failure, chronic obstructive pulmonary disease, or community-acquired pneumonia being discharged home from three academic acute care hospitals in Ontario, Canada. Semi structured interviews were conducted with participants within one week following their discharge from hospital. Interviews were audiotaped and transcribed. Five independent researchers participated in an iterative process of coding, reviewing, and analyzing the interviews using direct content analysis. Results In total, 27 participants completed qualitative interviews. Analysis revealed the role of the caregiver to be critical in its relation to the ability of patients to understand and adhere to discharge instructions. Within the topic of caregiving, we draw on three areas of insight: The first clarified how caregivers support patients after they are discharged home from the hospital. The second highlighted how caregiver involvement impacts patient understanding and adherence to discharge instructions. The third revealed system factors that influence a caregiver's involvement when receiving discharge instructions. Conclusion Caregivers play an important role in the transition of a complex medical patient by impacting a patient's ability to understand and adhere to their discharge instructions. The themes identified in this paper highlight opportunities for healthcare providers and institutions to effectively involve caregivers during transitions from acute care hospitals to home.

We explored the severity of binge eating, loss of control over eating, emotional eating, and night eating before bariatric surgery and annually for 3 years following surgery. We also assessed the impact of post-operative eating psychopathology on weight outcomes. Eight hundred forty-four patients participated in this prospective cohort study. Demographic factors, self-report measures of eating pathology (BES, NEQ, EES, EDE-Q), and weights (kg) were collected pre-surgery and annually for 3 years after surgery. The severity of problematic eating behaviors decreased after surgery and remained lower than baseline throughout follow-up. An increase was noted in binge eating scores (change in mean score ± SD = 0.85 ± 4.71; p = 0.002), emotional eating scores (2.00 ± 13.63; p = 0.033), and loss of control eating scores (1.11 ± 7.01; p

Background Enhanced recovery after surgery (ERAS) programs incorporate evidence-based practices to minimize perioperative stress, gut dysfunction, and promote early recovery. However, it is unknown which components have the greatest impact. Objective This study aims to determine which components of ERAS programs have the largest impact on recovery for patients undergoing colorectal surgery. Methods An iERAS program was implemented in 15 academic hospitals. Data were collected prospectively. Patients were considered compliant if >75% of the preoperative, intraoperative, and postoperative predefined interventions were adhered to. Optimal recovery was defined as discharge within 5 days of surgery with no major complications, no readmission to hospital, and no mortality. Multivariable analysis was used to model the impact of compliance and technique on optimal recovery. Results Overall, 2876 patients were enrolled. Colon resections were performed in 64.7% of patients and 52.9% had a laparoscopic procedure. Only 20.1% of patients were compliant with all phases of the pathway. The poorest compliance rate was for postoperative interventions (40.3%) which was independently associated with an increase in optimal recovery (RR = 2.12, 95% CI 1.81-2.47). Compliance with ERAS interventions remained associated with improved outcomes whether surgery was performed laparoscopically (RR = 1.55, 95% CI 1.23-1.96) or open (RR = 2.29, 95% CI 1.68-3.13). However, the impact of ERAS compliance was significantly greater in the open group (P Conclusions Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach.

Background Routine preoperative mechanical bowel preparation (MBP) for left-sided colorectal resections remains controversial. This study aims to evaluate the association between MBP and 30-day anastomotic leaks. Methods A retrospective cohort study was conducted using data from the National Surgical Quality Improvement Program from 2011 to 2012. Multiple imputation was used for missing data, and a multivariable logistic regression was performed to adjust for clinically relevant variables. A propensity score–adjusted model was performed as a sensitivity analysis. Results A total of 2,581 patients (57%) received preoperative MBP, whereas 1,935 (43%) did not. The 30-day anastomotic leak rate with and without preoperative MBP was 3.1% and 5.1%, respectively. After covariate adjustment, MBP omission was significantly associated with a 40% increased odds of 30-day anastomotic leaks (odds ratio 1.41, P = .04, 95% confidence interval 1.01 to 1.93). Conclusions MBP omission was associated with a higher rate of 30-day anastomotic leaks. A large, well-designed, randomized controlled trial is needed to further evaluate this relationship.

Laparoscopic resection has been considered a relative contraindication for T4 colonic and rectal lesions due to concern over inadequate margins. The objective of this study was to compare planned laparoscopic and open resections of T4 lesions with respect to the positive margin rate.Data were obtained from the American College of Surgeons National Surgical Quality Improvement Program participant use file to perform a retrospective cohort analysis. The study population consisted of patients that underwent a colorectal resection for a primary T4 lesion during 2011 and 2012. A multiple logistic regression analysis was conducted to determine the adjusted odds ratio (OR) of positive margins based on surgical approach. An inverse probability of treatment weighting (IPTW) analysis was used to account for confounding by indication. A sensitivity analysis including only "as-treated" cases was also performed.The sub-selected population consisted of 455 and 406 patients in the laparoscopic and open group, respectively. In the original cohort, demographic variables were similar. The open group had a higher incidence of comorbidities, metastatic disease, and emergency cases. Laparoscopic surgery was found to be no different than open surgery with respect to positive margin status (OR 1.10, p = 0.54). After IPTW adjustment, surgical approach remained a nonsignificant predictor of positive margins (OR 1.18, p = 0.31). The "as-treated" analysis also showed that surgical approach had no significant effect on the positive margin rate (OR 1.24, p = 0.24).Using this large national surgical database, select patients with T4 lesions who underwent planned laparoscopic colorectal resections did not have a significantly higher positive margin rate compared with patients with open operations. Further research is needed to identify the role of laparoscopy in managing T4b lesions before any consensus can be reached regarding its application in locally advanced colon cancer.

Current risk stratification tools for patients with colorectal cancer (CRC) rely on final surgical pathology but may be improved with the addition of novel serum biomarkers. The objective of this study was to evaluate the utility of preoperative NLR and PLR in predicting long-term oncologic outcomes in patients with operable CRC. All patients who underwent curative resection for adenocarcinoma at a large tertiary academic hospital were identified. High NLR/PLR was evaluated preoperatively and defined by maximizing log-rank statistics. Recurrence-free survival (RFS) and overall survival (OS) were calculated using the Kaplan–Meier method and compared by the log-rank test. Univariate and multivariable Cox proportional hazard regression was used to identify associations with outcome measures. A total of 549 patients were included in the study. High NLR (≥2.6) was associated with worse RFS (hazard ratio [HR] 2.03, 95 % confidence interval [CI] 1.48–2.79, p

Recent findings have shown that the neutrophil-to-lymphocyte ratio (NLR) is prognostic for gastrointestinal stromal tumors (GIST). The platelet-to-lymphocyte ratio (PLR) can predict outcome for several other disease sites. This study evaluates the prognostic utility of NLR and PLR for patients with GIST. All patients who had undergone surgical resection for primary, localized GIST from 2001 to 2011 were identified from a prospectively maintained database. Recurrence-free survival (RFS) was calculated by the Kaplan–Meier method and compared by the log-rank test. Univariate Cox proportional hazard regression models were used to identify associations with outcome variables. The study included 93 patients. High PLR [≥245; hazard ratio (HR) 3.690; 95 % confidence interval (CI) 1.066–12.821; p = 0.039], neutrophils (HR 1.224; 95 % CI 1.017–1.473; p = 0.033), and platelets (HR 1.005; 95 % CI 1.001–1.009; p = 0.013) were associated with worse RFS. Patients with high PLR had 2- and 5-year RFS of 57 and 57 %, compared with 94 and 84 % for those with low PLR. High NLR (≥2.04) was not associated with reduced RFS (p = 0.214). Whereas more patients in the high PLR group had large tumors (p = 0.047), more patients in the high NLR group had high mitotic rates (p = 0.016) than in the low-ratio cohorts. Adjuvant therapy was given to 41.2 % of the patients with high PLR (p = 0.022). The patients with high PLR/NLR had worse nomogram-predicted RFS than the patients with low PLR/NLR. High PLR was associated with reduced RFS. The prognostic ability of PLR to predict recurrence suggests that it may play a role in risk-stratification schemes used to determine which patients will benefit from adjuvant therapy.

Colonoscopy has a reported localization error rate as high as 21% in detecting colorectal neoplasms. Preoperative repeat endoscopy has been shown to be protective against localization errors. There is a paucity of literature assessing the utility of staging computerized tomography (CT) and repeat endoscopy as diagnostic tools for detecting localization errors following initial endoscopy. The objective of this study is to determine the diagnostic characteristics of staging CT and repeat endoscopy in correcting localization errors at initial endoscopy. A retrospective cohort study was conducted at a large tertiary academic center between January 2006 and August 2014. All patients undergoing surgical resection for CRC were identified. Group comparisons were conducted between (1) patients that underwent only staging CT (staging CT group), and (2) patients that underwent staging CT and repeat endoscopy (repeat endoscopy group). The primary outcome was localization error correction rate for errors at initial endoscopy. 594 patients were identified, 196 (33.0%) in the repeat endoscopy group, and 398 (77.0%) patients in the staging CT group. Error rates for each modality were as follows: initial endoscopy 8.8% (95% CI 6.5–11.0), staging CT 9.3% (95% CI 6.5–11.0), and repeat endoscopy 2.6% (95% CI 0.3–4.7); p

Studies exploring the impact of pre-surgery psychiatric status as a predictor of health related quality of life (QOL) after bariatric surgery have been limited to short-term follow-up and variable use of psychosocial measures. We examined the effect of pre-operative psychiatric factors on QOL and weight loss 2-years after surgery.156 patients participated in this prospective cohort study, the Toronto Bariatric Psychosocial Cohort Study, between 2010 and 2014. Patients were assessed pre-surgery for demographic factors, weight, psychiatric diagnosis using the MINI International Neuropsychiatric Interview and symptom measures for QOL, depression and anxiety at pre-surgery and at 1 and 2years post-surgery.At 2-years post-bariatric surgery, patients experienced a significant decrease in mean weight (-48.43kg, 95% [-51.1, -45.76]) and an increase only in physical QOL (+18.91, 95% [17.01, 20.82]) scores as compared to pre-surgery. Multivariate regression analysis identified pre-surgery physical QOL score (p0.001), younger age (p=0.005), and a history of a mood disorder as significant predictors of physical QOL. Only a history of a mood disorder (p=0.032) significantly predicted mental QOL (p=0.006). Pre-surgery weight (p0.001) and a history of a mood disorder (p=0.047) were significant predictors of weight loss 2-years post-surgery.Bariatric surgery had a sustained impact on physical QOL but not mental QOL at 2-years post-surgery. A history of mood disorder unexpectedly increased physical QOL scores and weight loss following surgery. Further research is needed to determine if these results are due to bariatric surgery candidate selection within this program.

Obesity is a global epidemic, and several surgical programs have been created to combat this public health issue. Although demand for bariatric surgery has grown, so too has the attrition rate. In this study we identify patient characteristics and operational interventions that have contributed to high attrition in a multistage, multidisciplinary bariatric surgery program.A retrospective study was conducted of 1,682 patients referred for bariatric surgery at the University Health Network in Toronto, Canada, from June 2008 to July 2011. Demographic information, presurgical assessment dates, and records describing operational changes were collected. Several penalized likelihood and mixed effects multivariable logistic regression models were used to determine whether patient characteristics, operational changes, and previous experience affected program completion and intermediate transitions between assessments.Although the majority of attrition appears to be the result of patient self-removal, males (odds ratio [OR] 0.511, 95% CI 0.392 to 0.663, p0.001), and individuals with active substance use (OR 0.223, 95% CI 0.096 to 0.471, p0.001) were less likely to undergo surgery. Operational practices had a detrimental effect on program completion (OR 0.590, 95% CI 0.456 to 0.762, p0.001). Conversely, patients with a BMI40 kg/m(2) (OR 1.756, 95% CI 1.233 to 2.515, p = 0.002) and those who lived within 25 to 300 km of the center (OR1.633, p0.001) were more likely to undergo surgery.Certain subgroups in the referral population were found to be at a higher risk of noncompletion. Specialized care pathways must be implemented to address this issue. Furthermore, careful consideration must be given to operational decisions because they may negatively affect access to care, as we have shown.

Background Laparoscopic adjustable gastric band (LAGB) insertion is a commonly performed bariatric procedure with low associated short-term risk. Given that a significant number of patients will require additional revision/removal procedures, overall morbidity may be underestimated. The objective of this study was to define the 30-day morbidity associated with LAGB removal and revision procedures. Methods Patients undergoing revision or removal of LAGB were identified within The American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) participant use file using current procedural terminology and ICD-9 coding. Patients having concurrent procedures were excluded. Primary outcomes included 30-day morbidity. The rate of complications in the removal/revision patients versus primary LAGB insertion was compared. We also analyzed trends over time. Results A total of 3,236 patients underwent LAGB removal (n = 1,580), revision (n = 1,111) or port site revision (n = 545) from 2006–2011. The overall 30-day complication rate was 5.6% (95% confidence interval [CI]: 4.8%, 6.4%) and was higher in patients undergoing LAGB removal with a 6.8% (95% CI: 5.6%, 8.1%) adverse event rate (2.5% infectious, 2.3% wound, 2.4% reoperation). A total of 24,438 patients underwent primary LAGB insertion within the data set with a 30-day complication rate of 2.6% (95% CI: 2.4%, 2.8%). Patients undergoing LABG removal had a significantly higher complication rate than those having primary LAGB insertion with an odds ratio of 2.72 (95% CI: 2.18, 3.37). The proportion of LAGB revision/removal compared to primary placement increased annually over the study period ( P for trend Conclusion The 30-day morbidity associated with LAGB revision is significant and higher than that associated with primary LAGB insertions. The potential need for future procedures and the associated additional morbidity should be considered when evaluating LAGB as a treatment option for morbid obesity.

There is controversy surrounding the safety and feasibility of next-day discharge following laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. The objective of this study was to determine if next-day discharge following LRYGB is comparable to standard discharge (i.e. postoperative day two) with respect to 30-day patient outcomes.A retrospective cohort analysis was performed using data from the American College of Surgeons' National Surgery Quality Improvement Program participant use files. The study population consisted of patients discharged on either postoperative day (POD) 1 or 2 that underwent an elective LRYGB for morbid obesity between 2005 and 2012. Patients were excluded if they had recent surgery, any relative contraindication to bariatric surgery, or any recorded complication/death during their principal admission. The primary outcome was 30-day overall complications and secondary outcomes were 30-day major complications and reoperations. A multiple logistic regression analysis was performed to evaluate each outcome based on discharge day.The study population consisted of 6,166 and 30,966 patients discharged on POD 1 and 2, respectively. No major clinical differences were found between the two groups with respect to relevant patient and operative characteristics. After adjustment, the odds ratios for 30-day overall complications, major complications, and reoperations with next-day discharge were 0.98 (p = 0.870, 95% CI [0.81-1.19]), 0.81 (p = 0.204, 95% CI [0.58-1.12]) and 1.06 (p = 0.717, 95% CI [0.79-1.41]), respectively. Body mass index ≥50, operative time ≥3 h, diabetes, dyspnea and hypertension were significant predictors for complications in patients discharged the next day.Using this large national surgical database, LRYGB patients discharged on POD 1 did not have a significantly higher rate of adverse events compared to patients discharged on POD 2. Understanding the important predictors of adverse events following LRYGB will help bariatric surgeons implement next-day discharge protocols based on the appropriate perioperative evaluation.

Morbid obesity is strongly associated with nonalcoholic fatty liver disease. However, the effect of underlying liver disease on clinical outcomes following bariatric surgery has not been well studied. This study aims to determine the effect of underlying liver disease on short-term outcomes in bariatric patients using the model of end-stage liver disease (MELD) scoring system as a practical measure of hepatic dysfunction. A retrospective cohort analysis was performed using data from the American College of Surgeons’ National surgery quality improvement program participant use files. The study population consisted of patients that underwent elective laparoscopic-stapled bariatric surgery for morbid obesity between 2005 and 2012. Patients were excluded if they had a bleeding disorder or renal failure requiring dialysis. The optimal MELD cut-off score to predict 30-day adverse events was determined and used to stratify patients into two groups. The primary outcome was 30-day adverse events, defined as a postoperative complication or reoperation. The secondary outcome was 30-day mortality. A multiple logistic regression was performed to adjust the odds ratio (OR) estimate for 30-day adverse events based on the MELD cut-off score. 38,875 patients were included in the study population. A MELD score of 7.9 was determined to be the optimal cut-off to predict 30-day adverse events based on the maximized linear combination of specificity and sensitivity. After adjusting for confounding, the OR estimates for 30-day adverse events and mortality using the cut-off score as the key predictor were 1.22 [95 % CI 1.06–1.41] and 2.33 [95 % CI 1.19–4.56], respectively. Using this large national surgical registry, bariatric patients with MELD scores ≥7.9 had a significant but marginal risk of 30-day adverse events and mortality. This suggests that severity of liver disease may affect bariatric surgery outcomes and should be considered during preoperative evaluations.

Laparoscopy in acute care surgery continues to expand. While adhesive small bowel obstruction (SBO) has traditionally been managed via an open approach, appropriately selected patients may benefit from laparoscopy. The objective of our study was to compare short-term postoperative outcomes in patients with adhesive SBO treated with laparotomy versus laparoscopy.Using the ACS NSQIP participant use files (2005-10), patients with a postoperative diagnosis of adhesive SBO were selected for inclusion in this study. Patients with bowel resections or concomitant procedures were excluded. Both univariate analyses and multivariate logistic regression were performed to compare 30-day outcomes in the open and laparoscopic groups.A total of 4,616 patients with adhesive SBO were identified: 3,697 (80.1%) and 919 (19.3%) in the open and laparoscopic groups, respectively. Mean operative time was similar in both groups. The mortality and overall complications were 84 (2.3%) and 819 (22.2%), respectively, in the open group compared to 7 (0.8%) and 81 (8.8%) in the laparoscopic group, with respective unadjusted odds ratios (ORs) of 0.33 (0.13-0.71, P0.01) and 0.39 (0.30-0.49, P0.01). The adjusted OR for overall complications was 0.46 (0.37-0.59, P0.01) favouring the laparoscopic group. The mean postoperative length of stay (LOS) was 8.4 days compared to 3.8 in the open and laparoscopic groups, respectively (P0.01).The laparoscopic approach to treating adhesive SBO resulted in significantly fewer complications and shorter LOS.

Approximately 175,000 umbilical hernia repairs are performed annually in the US. Controversy exists regarding the optimal approach for the elective repair of primary umbilical hernias.The objective of this study was to compare 30-day outcomes of elective primary open (OHR) and laparoscopic (LHR) umbilical hernia repairs, using a prospectively collected dataset.We performed a retrospective cohort study using the American College of Surgeons National Surgery Quality Improvement Program Participant Use Files during 2009 and 2010. Current Procedural Terminology and post-operative International Classification of Diseases, Ninth Revision diagnostic codes were used to identify primary umbilical hernia repairs. Primary outcomes included composite endpoints of 30-day mortality, and major and overall complications. Univariate analyses and multivariate logistic regression were performed controlling for relevant patient characteristics. Secondary outcomes included operative time and hospital length of stay (LOS).Overall, 14,652 patients were identified-13,109 (89.5 %) OHR and 1543 (10.5 %) LHR. Univariate analyses of primary outcomes demonstrated similar 30-day morbidity and mortality between groups. In our multivariate model, however, after controlling for body mass index, gender, American Society of Anesthesiologists class, and chronic obstructive pulmonary disease, the odds ratio (OR) for overall complications favored LHR (OR 0.60; p = 0.01). This difference was driven primarily by the reduced wound complication rate in the LHR group [OR 0.41 (0.20, 0.78); p = 0.005]. LHR was associated with significantly longer operative time [57.7 min (SD 32.6) vs. 38.3 min (SD 22.9); p0.001], longer LOS [0.29 days (SD 0.68) vs. 0.17 days (SD 1.47); p = 0.001], and an increased rate of respiratory (0.52 vs. 0.10 %; p0.001) and cardiac (0.26 vs. 0.05 %; p = 0.005) complications.This study identified potential decreased total and wound morbidity associated with LHR for elective primary umbilical hernia repairs at the expense of increased operative time, LOS, and respiratory and cardiac complications. These results should be considered within the context of a retrospective study with its inherent risks of bias and limitations.

Background Major depressive disorder has been shown in some studies to attenuate weight loss and psychosocial outcomes following surgery. Given the potential implications of depression on surgery outcomes, presurgery psychiatric assessment is recommended to assess suitability for bariatric surgery. Objectives The purpose of this study was to examine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) in detecting depression in bariatric surgery candidates. Methods Bariatric surgery candidates (n = 244) completed the PHQ-9 and the Mini International Neuropsychiatric Interview (MINI) as part of their presurgery psychiatric assessment. The operating characteristics of the PHQ-9 were examined. The study was replicated in an independent sample of bariatric surgery candidates (n = 275). Results Rates of current and lifetime major depressive episodes were 1.6% to 3.8% and 33.8% to 35.5%, respectively, as assessed by the MINI. According to the PHQ-9, 52.5% to 54.9% of patients exceeded the cutoff for moderate depression (PHQ-9 ≥ 10), and 27.6% to 29.1% for moderate severe depression (PHQ-9 ≥ 15). The optimal dichotomization cutoff point on the PHQ-9 was ≥15 in both studies (sensitivity 75%, specificity 75% to 76%). Conclusions Our results suggest that the PHQ-9 has adequate operating characteristics compared with a criterion standard measure. A PHQ-9 cutoff of 15 is recommended to identify bariatric surgery candidates who may require further assessment of depressive symptoms.

Language preference is currently being used in clinical practice to determine whether an interpreter is needed. The concordance of ability to communicate and language proficiency with each other and to language preference was measured with kappa agreement scores, sensitivity and specificity among 1,000 patients surveyed in Montreal, Canada. Though concordance between language preference and language proficiency or ability to communicate was moderate, both variables had low sensitivity (69 and 55 % respectively). A total of 25 % of persons with limited language proficiency and 15 % of those with limited ability to communicate were not identified to have a language preference for their mother tongue. Also, 31 and 45 % of those who preferred to be served in their mother tongue had good language proficiency and good ability to communicate. When assessing a patients' need for an interpreter, language preference is insufficient as a stand-alone question.