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Objective To describe patterns of pages communication to general surgery (GS) residents, identify the need for and develop strategies to improve interprofessional communication. Design Retrospective cohort study. Setting General surgery (GS) service at a tertiary care academic institution, Sunnybrook Health Sciences Centre, in Toronto, Ontario, Canada. Participants All pages sent to GS residents over 4 weeks at an academic institution. Timing, training level of receiver and content of pages were captured. Results Communication priority was assigned by 2 independent reviewers—low (121+ min), medium (31-120 min), high (6-30 min), and immediate (0-5 min) priority. Overall, 2 independent reviewers analyzed pages’ content through an inductive process, and generated themes. Of 2025 pages retrieved, 963 (47.5%) contained exclusively a call back number. A median of 74 pages per day (range: 43-116) were received, with median page interval of 9.4 minutes (range: 0-640). Junior residents received 79.5% of pages. Timing of the pages was 43.9% weekday shift, 31.8% weeknight shift, and 24.3% weekend call. Communication priority was deemed low for 35.4% of pages, medium for 32.3%, high for 12.4%, and immediate for 0.7%. Content analysis of 1062 pages generated 5 major themes: nonurgent medical issue (54.0%), administrative (15.3%), communication (13.5%), emergencies (4.8%), and GS consultation requests (4.0%). Priority and content of pages varied according to training level and page timing. Conclusions Pages to GS residents were frequent and most often of low priority. They were seldom related to urgent medical matters. Education and new communication strategies are warranted to reduce low priority pages.

This is the last of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

This is the fourth of five manuscripts reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

OBJECTIVES: TNM stage is the preeminent cancer staging system and a fundamental determinant of disease prognosis. Our goal was to evaluate the predictive power of TNM stage for gastric adenocarcinoma (GAC), in a low-incidence country. METHODS: A province-wide chart review of GAC patients diagnosed from April 1, 2005 to March 31, 2008 was conducted in Ontario and linked to routinely collected vital status data with a follow-up on March 31, 2012. TNM staging was classified using the sixth and seventh Union International for Cancer Control/American Joint Committee on Cancer editions. Kaplan-Meier and log-rank tests compared stage-stratified survival estimates. Discrimination was evaluated using Harrell’s C statistic. RESULTS: The cohort included 2366 patients. One- and 5-year survival was 43% and 17%. Using the sixth edition, 9% of patients had stage I disease, 5.4% stage II, 7.3% stage III, and 64% stage IV; 15% were not staged. Using the seventh edition, 9% were stage I, 7.7% stage II, 16% stage III, and 54% stage IV; 14% were not staged. Stage-stratified 5-year survival ranged from 68% to 7% with the sixth edition and from 70% to 4% with the seventh edition. Harrell’s C statistic was 0.64 (0.63–0.65) for the broad sixth edition staging categories and 0.68 (0.67–0.69) for the broad seventh edition. Discriminative power was similar for the refined stage categories and across multiple subgroup analyses; it was best in non-metastatic patients. CONCLUSION: Existing staging systems for GAC used in North America predict individualized prognosis poorly. The creation of a more complex prediction tool is necessary to provide accurate and precise prognostication information to oncologists, patients, and their families. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.17269/s41997-018-0102-1) contains supplementary material, which is available to authorized users.

This is the second of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

This is the first of five articles reviewing the historical origins of some of the more commonly used surgical instruments and takes “time out” to remind current surgeons about the surgical pioneers on whose shoulders they now stand and whose inventions they now use.

The recent publication of 5-year survival data for the Italian Gastric Cancer Study Group (IGCSG) D1 versus D2 lymphadenectomy for gastric cancer trial adds important data for analysis of whether a D2 lymphadenectomy improves survival. Systematic searches were conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1985 to February 1, 2014. Meta-analyses were performed using RevMan version 5 software. Long-term outcomes were analyzed. Subgroup analyses of T and N stage were performed. Outcomes of four randomized, controlled trials involving 1,599 patients (823 D1: 776 D2) enrolled from 1982 to 2005 were included for qualitative analysis and quantitative meta-analysis. Despite the addition of long-term survival data from the IGCSG, 5-year overall and nodal status survival was similar between D1 and D2 trials. However, subgroup analysis revealed a survival benefit for T3 patients (odds ratio 1.64, 95 % confidence interval 1.01–2.67) and a trend for survival benefit for advanced nodal stage (odds ratio 1.36, 95 % confidence interval 0.98–1.87) with D2 compared with D1 lymphadenectomy. As recent studies have demonstrated comparable short-term surgical outcomes for both D1 and D2 lymphadenectomies, consideration should be made for more extensive lymph node dissection among patients with advanced stage.

The rapid evolution of gastric cancer treatment in the face of escalating costs mandates thorough cost-effectiveness analyses to optimally direct future research and decision making. Relative to other cancer sites, the literature lacks high-quality economic evaluations to supplement clinical efficacy and effectiveness studies. As the fourth most commonly diagnosed cancer and the third leading cause of cancer-related death [1], gastric cancer is a major clinical and financial burden. Yet, very few estimations and assessments of overall costs of existing treatment methods or evaluations of cost effectiveness have been performed and fewer still meet current standards of high-quality methodology. Existing reports are often far from transparent, and very few studies present their findings according to established guidelines for the reporting of health economic data [2]. Furthermore, the few studies that have examined the overall costs of a gastric cancer diagnosis and treatment have determined that it is one of the most expensive cancers to treat on a per-patient basis [3, 4]. In the last 30 years, fewer than 30 papers have been published in English attempting to assess the costs of a gastric cancer diagnosis or explicitly compare the costs and benefits of treatment alternatives. In comparison, using the MeSH heading ‘‘Costs and Cost Analysis’’ in MEDLINE, over 300 review articles are identified for breast cancer, over 300 review articles identified for colorectal cancer, and over 100 review articles for prostate cancer; thus indicating that enough primary literature exists to generate these numerous reviews. In addition to the scientific literature, rigorous health technology assessments for new drugs and technologies are more commonly performed by government regulatory bodies such as the National Institute for Health and Care Excellence (NICE) and published as peer-reviewed reports. Searching the NICE guidance website uncovered an additional six technology appraisals since 2004, and one intervention appraisal [5]. As a clear disparity exists for economic evaluations for gastric cancer, we do not have an evidence-based understanding of how these costs are accumulated, or a comparative ratio of costs to benefits of commonly used treatment options to guide decision making. Few studies published in the last 20 years come from North America or Europe [3, 4, 6–9]. The majority of work evaluating the economic impact of gastric cancer and its various treatment strategies was performed in Asia, where the incidence of disease is much higher, and a larger proportion of early curative gastric cancer is diagnosed and A. L. Mahar A. Johnson Department of Public Health Sciences, Queen’s University, Kingston, Canada

BACKGROUND: Postoperative surveillance following curative-intent resection of colorectal cancer (CRC) is variably performed due to existing guideline differences and to the limited data supporting different strategies.OBJECTIVES: To examine population-based rates of surveillance imaging and endoscopy in patients in Ontario following curative-intent resection of CRC with no evidence of recurrence, as well as patient or disease factors that may predispose certain groups to more frequent versus less frequent surveillance; to provide insight to the care patients receive in the presence of conflicting guidelines, in efforts to help improve care of CRC survivors by identifying any potential underuse or overuse of particular surveillance modalities, or inequalities in access to surveillance.METHOD: A retrospective cohort study was conducted using data from the Ontario Cancer Registry and several linked databases. Ontario patients undergoing curative-intent CRC resection from 2003 to 2007 were identified, excluding patients with probable disease relapse. In the five-year period following surgery, the number of imaging and endoscopic examinations was determined.RESULTS: There were 4960 patients included in the study. Over the five-year postoperative period, the highest proportion of patients who underwent postoperative surveillance received the following number of tests for each modality examined: one to three abdominopelvic computed tomography (CT) scans (n=2073 [41.8%]); one to three abdominal ultrasounds (n=2443 [49.3%]); no chest CTs, one to three chest x-rays (n=2385 [48.1%]); and two endoscopies (n=1845 [37.2%]). Odds of not receiving any abdominopelvic imaging (CT or abdominal ultrasound) were higher in those who did not receive adjuvant chemo-therapy (OR 6.99 [95% CI 5.26 to 9.35]) or those living in certain geographical areas, but were independent of age, sex and income. Nearly all patients (n=4473 [90.2%]) underwent ≥1 endoscopy at some point during the follow-up period.CONCLUSION: In contrast to findings from similar studies in other jurisdictions, most Ontario CRC survivors receive postoperative surveillance with imaging and endoscopy, and care is equitable across sociodemographic groups, although unexplained geographical variation in practice exists and warrants further investigation.

Despite recent declining incidence, gastric cancer remains one of the most common cancers worldwide. Its treatment involves a multidisciplinary team to ensure implementation of investigated pre-operative and post-operative treatment strategies to improve survival. Our aim is to discuss the current role of the surgeon in improving survival of gastric cancer patients.

Before undergoing curative-intent resection of gastric adenocarcinoma (ga), most patients undergo abdominal computed tomography (ct) imaging to determine contraindications to resection (local invasion, distant metastases). However, the ability to detect contraindications is variable, and the literature is limited to single-institution studies. We sought to assess, on a population level, the clinical relevance of preoperative ct in evaluating the resectability of ga tumours in patients undergoing surgery. In a provincial cancer registry, 2414 patients with ga diagnosed during 2005&ndash, 2008 at 116 institutions were identified, and a primary chart review of radiology, operative, and pathology reports was performed for all patients. Preoperative abdominal ct reports were compared with intraoperative findings and final pathology reports (reference standard) to determine the negative predictive value (npv) of ct in assessing local invasion, nodal involvement, and intra-abdominal metastases. Among patients undergoing gastrectomy, the npv of ct imaging in detecting local invasion was 86.9% (n = 536). For nodal metastasis, the npv of ct was 43.3% (n = 450). Among patients undergoing surgical exploration, the npv of ct for intra-abdominal metastases was 52.3% (n = 407). Preoperative abdominal ct imaging reported as negative is most accurate in determining local invasion and least accurate in nodal assessment. The poor npv of ct should be taken into account when selecting patients for staging laparoscopy.

Appreciation and study of hepatic arterial anatomical variability is essential to the performance of a pancreaticoduodenectomy to avoid surgical complications such as bleeding, hepatic ischemia/failure, and anastomotic leak/stricture. Awareness of this variability permits the surgeon to adapt the surgical technique to deal with anomalies identified preoperatively or intraoperatively thereby preventing unnecessary surgical morbidity and mortality. The objective of our study is to provide a comprehensive review of the anatomic arterial anomalies and discuss surgical strategies that will equip the surgeon to deal with all anomalies that may be encountered a priori or en passant during the course of a Whipple procedure.

Cardiac veins have long stood in the shadow of their more extensively studied counterparts, the coronary arteries. The clinical importance of the coronary venous system, nonetheless, should not be underestimated. Intricate and beneficial therapeutic options are increasingly being developed that depend on knowledge of the structure of this venous network. Such interventions have been shown greatly to promote cardiac health, and to enhance the efficacy of cardiac pacing. A comprehensive appreciation of the architecture of the coronary venous system, therefore, is crucial to optimal cardiac care. It is possible to provide an overview of the arrangement of the cardiac veins, with the larger veins draining to the coronary sinus, and thence to the right atrium, but with smaller and minimal veins draining directly to the cavities of the atrial chambers. The venous pathways, nonetheless, are highly variable, making exceptions the commonly accepted rule. As such, unique solutions for imaging, and simple attentiveness to possible venous variations, can greatly enhance clinical outcomes. For example, identifying the diameter, course, and valves of the cardiac veins allows for anticipation of impediments during interventional procedures, and allows for informed clinical decision-making. Also of significance is awareness of alternate arrangements that may be encountered in terms of venous drainage, and the importance of intramural venous collecting spaces in these patterns. The objective of our review, therefore, is to explore and describe the anatomical distribution of the coronary veins.

Jules Germain Cloquet, the famed French anatomist, surgeon, and professor, may not be remembered as one of the pioneers of hernia surgery; however, his contributions have provided surgeons with detailed anatomical descriptions that have been useful in developing innovative surgical techniques. Cloquet has many eponyms associated with him, including: Cloquet's fascia, Cloquet's gland or lymph node of Cloquet, Cloquet's hernia, Cloquet's ligament, Cloquet's canal, and Cloquet's septum. A man blessed with artistic talents, Cloquet was the author of many theses, as well as anatomical volumes that were comparable to the works of other great anatomists of his time. His first thesis, entitled Recherches Anatomiques sur les Hernies de l'Abdomen, described the locations where inguinal and crural herniae are more likely to occur in terms of the cremaster muscle, the peritoneum, and the spermatic vessels. Wax sculpture training required extensive knowledge in the natural sciences, anatomy, physiology, and pathology, as were acquired by Jules Cloquet as a pupil of Achille-Cléophas Flaubert, the father of the famous French novelist Gustave Flaubert (author of Madame Bovary). Cloquet attracted many pupils with his innovative teaching style and implementation of anatomical preparations, drawings, and sketches on the black board with chalk. The legacy of this famed individual lives on today in the anatomical structures described by Cloquet.

Hernias through the triangle of Petit (TP) are uncommon. The anatomy of the TP is known to be variable, yet quantitative data are scant.The triangle was observed in 80 adult cadavers and its dimensions and surface area were measured.On the basis of surface area we classified the triangles into four types. Type I or small TP, with a surface area of8 cm2, accounted for 43.7% of our specimens. Type II (26.2%) were intermediate in size, with a surface areas of 8-12 cm2. Type III (12.5%) were large triangles with surface areas12 cm2. Finally, Type IV (17.5%) were not triangles. In these, the latissimus dorsi was covered by the external abdominal oblique muscle.We hope these data will help prediction of which patients are at greater risk of herniation through the TP.

Vincent Alexander Bochdalek, Czech anatomist and professor, was one of the pioneers in describing congenital diaphragmatic hernias in newborns. Interestingly, there is very little in the literature and almost nothing in the English literature regarding this important medical figure. A dedicated individual, Bochdalek had great perseverance, which allowed him to surpass obstacles in both his personal life and career. He is recognized for his accurate description of posterior diaphragmatic herniation, for which during his lifetime, there was no treatment. In addition, Bochdalek has multiple eponyms in his honor: ganglion Bochdalecki, Bochdalek's basket, and the valves of Bochdalek. Always steadfast in his beliefs, Bochdalek fought for the creation of anatomy labs in Prague against society pressures. His devoted study of anatomy, especially of congenital diaphragmatic hernias, laid the foundation for the successful surgical correction of this once lethal anomaly.

Don Manuel Louise Antonio de Gimbernat y Arbos, Spanish anatomist and surgeon, was one of the pioneers during the "age of dissection" (late eighteenth century). A bright young mind, Gimbernat was confident and audacious, which allowed him to become a recognized surgeon with a famed reputation that influenced his colleagues internationally. The Spaniard was most widely recognized for his advancements in the treatment of strangulated femoral hernias, and the lacunar ligament was named "Gimbernat's ligament" in his honor. In 1793, he published Nuevo Metodo de operar en la Hernia Crural dedicated to King Charles IV, which was translated into English by Thomas Beddoes 2 years later. Gimbernat's daring procedures helped improve safety and efficiency of hernia surgery. A person of great determination, he was known as a brilliant, meticulous, and creative man who exemplified the importance of surgeons. His devoted study of anatomy, especially of inguinal anatomy, allowed him to devise a legendary surgical technique in repairing femoral hernias, influencing renowned surgeons of his time and thereafter.

Despite declining incidence, gastric cancer remains one of the most common cancers worldwide. Early detection in population-based screening programs has increased the number of cases of early gastric cancer, representing approximately 50% of newly detected gastric cancer cases in Asian countries. Endoscopic mucosal resection and endoscopic submucosal dissection have become the preferred therapeutic techniques in Japan and Korea for the treatment of early gastric cancer patients with a very low risk of lymph node metastasis. Laparoscopic and robotic resections for early gastric cancer, including function-preserving resections, have propagated through advances in technology and surgeon experience. The aim of this paper is to discuss the recent advances in minimally invasive approaches in the treatment of early gastric cancer.

BackgroundComparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients.MethodsA Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters.ResultsIn base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age.ConclusionsHR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values.