Search

Background: Associations between procedure volumes and outcomes can inform minimum volume standards and the regionalization of health services. Robot-assisted surgery continues to expand globally; however, data are limited regarding which hospitals should be using the technology. Study design: Using administrative health data for all residents of Ontario, Canada, this retrospective cohort study included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using 4 arms (RPL-4) between January 2010 and September 2021. Associations between yearly hospital volumes and 90-day major complications were evaluated using multivariable logistic regression models adjusted for patient characteristics and clustering at the level of the hospital. Results: A total of 10,879 patients were included, with 7567, 1776, 724, and 812 undergoing a RARP, TRH, RAPN, and RPL-4, respectively. Yearly hospital volume was not associated with 90-day complications for any procedure. Doubling of yearly volume was associated with a 17-min decrease in operative time for RARP (95% confidence interval [CI] − 23 to − 10), 8-min decrease for RAPN (95% CI − 14 to − 2), 24-min decrease for RPL-4 (95% CI − 29 to − 19), and no significant change for TRH (− 7 min; 95% CI − 17 to 3). Conclusion: The risk of 90-day major complications does not appear to be higher in low volume hospitals; however, they may not be as efficient with operating room utilization. Careful case selection may have contributed to the lack of an observed association between volumes and complications. [ABSTRACT FROM AUTHOR]

Background: Robot-assisted surgery has been rapidly adopted. It is important to define the learning curve to inform credentialling requirements, training programs, identify fast and slow learners, and protect patients. This study aimed to characterize the hospital learning curve for common robot-assisted procedures. Study design: This cohort study, using administrative health data for Ontario, Canada, included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using four arms (RPL-4) between 2010 and 2021. The association between cumulative hospital volume of a robot-assisted procedure and major complications was evaluated using multivariable logistic models adjusted for patient characteristics and clustering at the hospital level. Results: A total of 6814 patients were included, with 5230, 543, 465, and 576 patients in the RARP, TRH, RAPN, and RPL-4 cohorts, respectively. There was no association between cumulative hospital volume and major complications. Visual inspection of learning curves demonstrated a transient worsening of outcomes followed by subsequent improvements with experience. Operative time decreased for all procedures with increasing volume and reached plateaus after approximately 300 RARPs, 75 TRHs, and 150 RPL-4s. The odds of a prolonged length of stay decreased with increasing volume for patients undergoing a RARP (OR 0.87; 95% CI 0.82–0.92) or RPL-4 (OR 0.77; 95% CI 0.68–0.87). Conclusion: Hospitals may adopt robot-assisted surgery without significantly increasing the risk of major complications for patients early in the learning curve and with an expectation of increasing efficiency. [ABSTRACT FROM AUTHOR]

Background: The evidence on the benefits and drawbacks of involving neurosurgical residents in the care of patients who undergo neurosurgical procedures is heterogeneous. We assessed the effect of neurosurgical residency programs on the outcomes of such patients in a large single-payer public health care system., Methods: Ten population-based cohorts of adult patients in Ontario who received neurosurgical care from 2013 to 2017 were identified on the basis of procedural codes, and the cohorts were followed in administrative health data sources. Patient outcomes by the status of the treating hospital (with or without a neurosurgical residency program) within each cohort were compared with models adjusted for a priori confounders and with adjusted multilevel models (MLMs) to also account for hospital-level factors., Results: A total of 46 608 neurosurgical procedures were included. Operative time was 8%-30% longer in hospitals with neurosurgical residency programs in 9 out of 10 cohorts. Thirty-day mortality was lower in hospitals with neurosurgical residency programs for aneurysm repair (odds ratio [OR] 0.30, 95% confidence interval [CI] 0.20-0.44), cerebrospinal fluid shunting (OR 0.52, 95% CI 0.34-0.79), intracerebral hemorrhage evacuation (OR 0.66, 95% CI 0.52-0.84), and posterior lumbar decompression (OR 0.32, 95% CI 0.15-0.65) in adjusted models. The mortality rates remained significantly different only for aneurysm repair (OR 0.19, 95% CI 0.05-0.69) and cerebrospinal shunting (OR 0.42, 95% CI 0.21-0.85) in MLMs. Length of stay was mostly shorter in hospitals with neurosurgical residents, but this finding did not persist in MLMs. Thirty-day reoperation rates did not differ between hospital types in MLMs. For 30-day readmission rates, only extracerebral hematoma decompression was significant in MLMs (OR 1.41, 95% CI 1.07-1.87)., Conclusion: Hospitals with neurosurgical residents had longer operative times with similar to better outcomes. Most, but not all, of the differences between hospitals with and without residency programs were explained by hospital-level variables rather than direct effects of residents., Competing Interests: Competing interests:: E. Kasper has received travel support from Steward Health Care. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Prolonged operative time is a well-known risk factor for surgical site infections (SSI). There remains limited literature regarding correlates of SSIs specific for general surgery procedures of longer duration. This study aims to identify potential risk factors of SSIs for colorectal and hepatobiliary surgeries of prolonged duration. Methods: A retrospective chart review was performed for elective colorectal and hepatobiliary procedures of prolonged operative duration (≥ 4 hours) from 2008-2011 at Sunnybrook Health Sciences Centre. Patient and procedural characteristics and compliance with local guidelines for main SSI prevention practices were evaluated. Multivariate analysis was performed to identify independent risk factors of SSI development. Results: There were 547 patients with operations ≥ 4 hours and 57 (10%) SSI cases - 43 (75%) deep/ superficial and 14 (25%) organ/space. Average age was 62, BMI 27.3, weight 77.1 kg, and operative time 366 minutes. Less than 40% of all patients received intra-operative antibiotic prophylaxis measures in accordance with local guidelines. Multivariate logistic regression identified operative time (OR 1.22, 95% CI = 1.09-1.36, P < 0.001) as associated with the development of SSIs. Multivariate analysis demonstrated a non-significant association for increasing odds of SSIs when intra-operative antibiotic re-dosing was not in accordance with local guidelines (OR 1.54, 95% CI = 0.82-2.89, P=0.177). Conclusions: Healthcare providers should anticipate a greater likelihood for SSIs following lengthy operations regardless of patient characteristics or procedural factors. There is a need to target the improvement of antibiotic re-dosing practices as a means to decrease SSIs. [ABSTRACT FROM AUTHOR]

Objectives: Routine preoperative axial imaging studies (CT/MRI) are not recommended for endometrioid endometrial cancer as they are unlikely to change management and may delay surgery. This study evaluated the association of receiving preoperative imaging on various outcomes., Methods: A population-based cohort of Endometrioid Endometrial Cancer cases from 2006 to 2016 were identified from the Cancer Registry in Ontario, Canada. Wait time to surgery, type of surgery and overall survival were evaluated in patients with and without preoperative imaging. Predictive factors for wait time > 56 days and aggressive surgery (radical hysterectomy / lymphadenectomy) were determined using multivariable regression analysis., Results: 13,050 cases were included. 22.6% of patients received preoperative imaging, mainly CT scans. Most patients (95.9%) received no neoadjuvant treatment. Patients with preoperative imaging were more likely to have neoadjuvant treatment (11.7% vs. 1.8%) and less likely to have surgery at 180 days post diagnosis (87.9% vs 94.6%). Patients with preoperative imaging had median wait time to surgery of 64 days (47-87), compared to 53 days (36-74) than those without imaging (p < 0.001). Multivariable modeling showed preoperative imaging was associated with decreased odds of having surgery within 56 days (OR = 0.68, 95% CI = 0.62-0.75), and increased odds (OR = 1.73, 95% CI = 1.53-1.95) of having aggressive surgery. The 5-year overall survival for patients with imaging was 84.8% versus 91.1% for patients without preoperative imaging., Conclusions: Preoperative imaging was associated with longer wait times to surgery, more aggressive surgery, surgery with a gynecologic oncologist and increased use of neoadjuvant and adjuvant treatment. In early-stage disease there was no observed improvement in overall survival for patients with preoperative imaging. Further research on potential benefits of preoperative imaging in higher risk patients is required., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: Since its introduction, endovascular aneurysm repair (EVAR) has become a mainstay in the treatment of abdominal aortic aneurysms (AAAs), resulting in the decline of open aneurysm repairs. The objective of this study was to determine whether reduced open aneurysm repair frequency has led to a reduction in perioperative efficiency and increase in postsurgical complications., Methods: A retrospective cohort study compared perioperative data and complications of 49 consecutive juxtarenal AAA (<1-cm neck) open repairs performed between 2014 and 2017 and 53 consecutive juxtarenal AAA controls (2005-2007) at The Ottawa Hospital. There was no change in surgical personnel during this 10-year comparison., Results: The Ottawa Hospital experienced a 61% decline in the number of open AAA repairs between the two time periods examined; 541 open AAA repairs and 86 EVARs were performed between 2005 and 2007, whereas 358 open AAA repairs and 385 EVARs were performed between 2014 and 2017. Age of participants significantly decreased in the 2014 to 2017 group (P = .01), as did the number of women undergoing open juxtarenal AAA repair (P = .05). Total operating room time and anesthesia time were longer in the 2014-2017 group (P = .02; P = .01), whereas surgical times remained consistent (P = .13). Suprarenal clamp time and blood loss during the procedure were decreased in the 2014-2017 group (P < .01; P < .01). Intensive care unit stay and overall hospital stay were not significantly different between groups (P = .77; P = .87); however, there were large standard deviations observed for the 2014-2017 group. As well, 18.4% of patients in the 2014-2017 group experienced postsurgical complications of Clavien-Dindo grade IIIa or higher compared with 11.3% of patients in the historical control group (P = .07). Mortality also trended toward an increase in the 2014-2017 group (P = .43)., Conclusions: The reduced rate of open repair performance at The Ottawa Hospital reflects the global trend toward EVAR. Anesthesia and operating room times increased during the period examined, reflecting a possible loss of expertise in the last decade. Complications also increased during this time for anatomically similar patients. Taken together, these findings may reflect a decreased institutional familiarity with open aneurysm repair and postsurgical care., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Summary: The cancellation of large numbers of surgical procedures because of the coronavirus disease 2019 (COVID-19) pandemic has drastically extended wait lists and negatively affected patient care and experience. As many facilities resume clinical work owing to the currently low burden of disease in our community, we are faced with operative booking protocols and procedures that are not mathematically designed to optimize efficiency. Using a subset of artificial intelligence called "machine learning," we have shown how the use of operating time can be optimized with a custom Python (a high-level programming language) script and an open source machine-learning algorithm, the ORTools software suite from the Google AI division of Alphabet Inc. This allowed the creation of customized models to optimize the efficiency of operating room booking times, which resulted in a reduction in nursing overtime of 21% - a theoretical cost savings of $469 000 over 3 years.

Objective: The impact of resident involvement in the operating room for common procedures in obstetrics and gynaecology can shed light on the resource demands of teaching. The objective of this study was to quantify the increased surgical time associated with teaching obstetrics and gynaecology resident trainees across a range of procedures known to require surgical assistance., Methods: This population-based retrospective cohort study compared surgical duration between academic (teaching) hospitals and community (non-teaching) hospitals. The cohort was made up of adult residents of Ontario between fiscal years 2002 and 2013 who were undergoing commonly performed obstetrics and gynaecologic procedures. The most commonly billed procedures requiring surgical assistance were included: cesarean section, anterior or posterior repair, anterior and posterior repair, salpingo-oophorectomy, myomectomy, ectopic pregnancy, total or subtotal hysterectomy, vaginal hysterectomy, and laparoscopic hysterectomy. Linked administrative databases held at the Institute of Clinical Evaluative Sciences (ICES) were used to define patient-, surgeon-, institution-, and procedure-related variables to limit confounding. Surgical duration, determined by anaesthetic billing records, was analyzed using a negative binomial regression., Results: The total cohort included 337 389 surgical procedures. Of these procedures, 28% (94 203 procedures) were conducted in academic settings. The mean surgical duration of the procedures of interest (excluding vaginal hysterectomy) was significantly longer in academic hospitals compared with community hospitals. With many controls for case variability, this time differential reflects the burden of teaching resident trainees and other learners in the academic environment. The operating time increased between 6% and 20% for cases completed in academic centres versus in the community. As an example, the mean surgical duration of cesarean sections was 20.6 minutes (19%) longer in academic centres. Furthermore, the data highlighted a trend of increased teaching time for laparoscopic procedures compared with open procedures. The time ratio was the greatest for salpingo-oophortectomy and surgical management of ectopic pregnancies. The additional cost of carrying out these nine procedures in academic centres during the study period was $16.3 million., Conclusion: The cost of teaching resident trainees is increased operative time. This increased surgical cost in a publicly funded system must be considered as funding models evolve., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Importance: Controversy exists about the preferred surgical approach for total hip arthroplasty (THA)., Objective: To determine whether an anterior approach is associated with lower risk of complications than either a lateral or posterior approach., Design, Setting, and Participants: Population-based retrospective cohort study of all adults in Ontario, Canada, who had undergone primary THA for osteoarthritis between April 1, 2015, and March 31, 2018. All patients were followed up over a 1-year period (study end date, March 31, 2019)., Exposures: Surgical approach (anterior vs lateral/posterior) for THA., Main Outcomes and Measures: Major surgical complications within 1 year (composite of deep infection requiring surgery, dislocation requiring closed or open reduction, or revision surgery). Outcomes were compared among propensity-score matched groups using Cox proportional hazards regression., Results: Of the 30 098 patients (mean [SD] age, 67 years [10.7 years]; 16 079 women [53.4%]) who underwent THA, 2995 (10%) underwent the anterior approach; 21 248 (70%), the lateral approach; and 5855 (20%) the posterior approach performed at 1 of 73 hospitals by 1 of 298 surgeons. All patients were followed up for 1 year. Compared with those undergoing the lateral or posterior approach, patients undergoing an anterior approach were younger (mean age, 65 vs 67 years; standardized difference, 0.17); had lower rates of morbid obesity (4.8% vs 7.6%; standardized difference, 0.12), diabetes (14.2% vs 19.9%; standardized difference, 0.15), and hypertension (53.4% vs 62.9%; standardized difference, 0.19); and were treated by higher-volume surgeons (median range, 111 procedures; interquartile range, 69-172 vs 77 procedures, interquartile range, 50-119 in the prior year; standardized difference, 0.55). Compared with 2993 propensity-score matched patients undergoing a lateral or posterior approach, the 2993 matched patients undergoing anterior approaches had a significantly greater risk of a major surgical complication (61 patients [2%] vs 29 patients [1%]; absolute risk difference, 1.07%; 95% CI, 0.46%-1.69%; hazard ratio, 2.07; 95% CI, 1.48 to 2.88)., Conclusions and Relevance: Among patients undergoing total hip arthroplasty, an anterior surgical approach compared with a posterior or lateral surgical approach was associated with a small but statistically significant increased risk of major surgical complications. The findings may help inform decisions about surgical approach for hip arthroplasty, although further research is needed to understand pain and functional outcomes.

Background: This study sought to identify risk factors associated with wound disruption following Caesarean section (CS) in women with class III obesity and to determine the value of individualized perioperative care plans in reducing its incidence., Methods: The study included women with class III obesity who underwent CS after 24 weeks of gestation at Mount Sinai Hospital, Toronto, Ontario between 2011 and 2015 and collected data on demographics, clinical history, and perioperative details. Multivariable logistic regression analysis was performed to identify factors likely to contribute to a higher incidence of wound disruption (level of evidence II-3B)., Results: Of the 334 identified cases, in women with a mean BMI of 48.20 ± 7.52 kg/m 2 , there were 60 cases of wound disruption (18%). The most common perioperative interventions involved Pfannenstiel skin incisions (75.6%), subcutaneous tissue closure (65.4%), use of pressure dressings (65%), and thromboprophylaxis (71.8%). On bivariable analysis, surgical time >1 hour (24.2% vs. 13.5%; OR 2.03; P = 0.017) and the use of thromboprophylaxis (20.1% vs. 10.6%; OR 2.22, P = 0.031) were associated with increased wound disruption, but these associations were attenuated on multivariable regression analysis., Conclusions: No single risk factor or perioperative intervention was independently associated with wound disruption. However, the use of individualized perioperative care plans resulted in fewer wound disruptions in our cohort when compared with published literature., (Copyright © 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Importance: Postoperative delirium in older adults receiving hip fracture surgery is associated with morbidity and increased health care costs, yet little is known of potential modifiable factors that may help limit the risks., Objective: To use population-wide individual-level data on the duration of hip fracture surgery to determine whether prolonged surgical times and type of anesthesia are associated with an increased risk of postoperative delirium., Design, Setting, and Participants: This retrospective population-based cohort study analyzed patients aged 65 years and older receiving hip fracture surgery between April 1, 2009, and March 30, 2017, at 80 hospitals in Ontario, Canada. Generalized estimated equations with logistic regression analysis were used to determine the relationship between procedure duration, type of anesthesia, and the occurrence of postoperative delirium. Restricted cubic splines were also generated to visualize this relationship. Data analysis was conducted from July to October 2018, revision in January 2019., Exposure: Surgery duration, measured as the total time in the operating room., Main Outcomes and Measures: A diagnosis of postoperative delirium during hospitalization., Results: Among 68 131 patients with surgically managed hip fracture (median [interquartile range] age, 84 [78-89] years; 72% women) identified, 7150 patients experienced postoperative delirium. In total, 26 853 patients (39.4%) received general anesthesia. Receiving general anesthesia was associated with a slightly higher rate of postoperative delirium compared with not receiving general anesthesia (2943 [11.0%] vs 4207 [10.2%]; P = .001). The risk for delirium increased with increased surgical duration-every 30-minute increase in the duration of surgery was associated with a 6% increase in the risk for delirium (adjusted odds ratio, 1.06; 95% CI, 1.03-1.08; P < .001). Prolonged surgical duration was associated with a higher incidence of postoperative delirium, and the risk was higher was in patients who had received general anesthesia (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; P < .001) than in those patients who did not receive GA (adjusted odds ratio, 1.04; 95% CI, 1.01-1.08; P = .01)., Conclusions and Relevance: Among older adults receiving hip fracture surgery, both an increased duration of surgery and receiving a general anesthetic were associated with an increased risk for postoperative delirium.

Study Objective: Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications., Design: Retrospective, multicenter, cohort study (Canadian Task Force classification II-2)., Setting: Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites., Patients: Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012., Intervention: ACS-NSQIP database., Measurements and Main Results: Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality., Conclusion: Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the effect of cumulative volume on all-cause morbidity and operative time., Background: Gastric bypass is an important public health procedure, but it is difficult to master with little data about how surgeon cumulative volume affects outcomes longitudinally., Methods: This was a longitudinal study of 29 surgeons during the first 6 years of performing bariatric surgery in a high-volume, regionalized center of excellence system. Cumulative volume was determined using date and time of the procedure. Cumulative volume was analyzed in blocks of 75 cases. The main outcome of interest was all-cause morbidity during the index admission and the secondary outcome was operative time., Results: Overall, 11,684 gastric bypasses were performed by 29 surgeons at 9 centers of excellence. The overall morbidity rate was 10.1% and short-term outcomes were related significantly to cumulative volume. Perioperative risk plateaued after approximately 500 cases and was lowest for surgeons who had completed more than 600 cases (odds ratio 0.53 95% confidence interval 0.26-0.96 P = 0.04) compared to the first 75 cases. Operative time also stabilized after approximately 500 cases, with an operative time 44.7 minutes faster than surgeons in their first 75 cases (95% confidence interval 37.0-52.4 min P < 0.001)., Conclusions: The present study demonstrated the clear, substantial influence of surgeon cumulative volume on improved perioperative outcomes and operative time. This finding emphasizes role of the individual surgeon in perioperative outcomes and that the true learning curve needed to master a complex surgical procedure such as gastric bypass is longer than previously thought, in this case requiring approximately 500 cases to plateau.

Background: Customized cutting block (CCB) was designed to ensure the accurate alignment of knee prostheses during total knee arthroplasty. Given the paucity of CCB efficacy data, we compare CCB with conventional cutting guide using a randomized controlled trial., Methods: One hundred eight osteoarthritic knee patients underwent total knee arthroplasty by one experienced surgeon were randomized to receive CCB (n = 54) or conventional cutting instrument (CCI) surgery (n = 54). The primary outcomes were limb alignment, prostheses position, and operative time. The secondary outcomes were hemodynamic alteration after surgery, functional outcomes (modified Western Ontario and McMaster University Osteoarthritis Index) and range of motion at 2 years after surgery., Results: Mean hip-knee-ankle angle in the CCB group was 179.4° ± 1.8° vs 179.1° ± 2.4° in the CCI group, Δ = 0 (95% confidence interval [CI] -0.6 to 1.1, P = .55). Mean operative time was faster in the CCB arm: 93 ± 12 vs 104 ± 12 minutes, Δ = 11 (95% CI -16.7 to -7.2, P < .0001). There were no differences in hemodynamic parameters, mean blood loss (446 [CCB] vs 514 mL [CCI], Δ = -68 [95% CI -138 to 31 mL, P = .21]), postoperative hemoglobin changes, incidence of hypotension (systolic <90 mm Hg), oliguria, and rates of blood transfusion. Functional outcomes and range of motion were also similar., Conclusion: There was no improvement in alignment, hemodynamic changes, blood loss, and knee functional outcomes. CCB reduced surgical time by 11 minutes in our population. CCB cost-effectiveness should be further investigated., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Tourniquets are still widely used in total knee arthroplasty (TKA), although they may be associated with several adverse effects. An observer-blinded, randomized, controlled trial was performed to evaluate the effects of tourniquet use in TKA., Methods: Fifty participants who underwent staged bilateral TKA were recruited for this study. The first-side TKA was randomly allocated to either long-duration tourniquet use or short-duration tourniquet use followed by a 3-month washout period and crossover to the other tourniquet strategy for the opposite-side TKA. Blood loss was monitored perioperatively. The operating time, allogeneic blood transfusion rate, thigh pain, knee pain, limb swelling, clinical outcome as measured by the Likert-type Western Ontario and McMaster University (WOMAC) score, straight leg raising and knee active range of motion (ROM) were also recorded., Results: The long-duration tourniquet group exhibited reduced total blood loss [-99.1 ml, 95 % confidence interval (CI) -168.1 to -30.1, P = 0.0411] and intraoperative blood loss (-225.2 ml, 95 % CI -369.5 to -80.9, P = 0.0071) compared with the short-duration tourniquet group. However, there were greater postoperative blood loss (69.6 ml, 95 % CI 21.1 to 118.2, P = 0.0282) and hidden blood loss (52.8 ml, 95 % CI 10.5 to 95.1, P = 0.0332) in the long-duration tourniquet group. The short-duration tourniquet group showed better outcomes for thigh and knee pain, limb swelling, WOMAC score at 6-week follow-up, straight leg raising and knee ROM. Similar allogeneic blood transfusion rates were observed for both groups., Conclusion: Total and intraoperative blood losses were reduced with the long-duration tourniquet use, whereas the short-duration tourniquet use would reduce postoperative and hidden blood losses without increasing the allogeneic blood transfusion rate. In addition, short-duration tourniquet use would result in faster recovery and less pain during the early rehabilitation period following TKA., Level of Evidence: I.

Aim: Despite transanal endoscopic microsurgery (TEM) being used for over 30 years, there has been slow adoption of this modality in many centres. There remains a paucity of research regarding the learning curve and early performance of surgeons who begin to offer TEM. We sought to determine predictors of longer rates of tumour excision and improvements in operative time in a newly established TEM programme., Method: All patients who underwent TEM at the Ottawa Hospital, Ottawa, Canada, between October 2009 and September 2014 were included. Data were abstracted through a retrospective chart review. The average rate of lesion excision (ARE) was calculated to standardize the operation time by size of the pathological specimen (min/cm 3 ), representing a measure of surgical efficiency. Surgical efficiency was plotted using restricted cubic splines. Predictors of higher ARE were determined using multivariable regression., Results: During the study period 108 patients underwent TEM. ARE was available for 95 patients of mean age 67.2 years. The mean ARE was 18.6 min/cm 3 . On adjusting for important covariates, the ARE improved with each additional case until 16 cases were completed. Significant predictors of higher ARE on multivariable analysis were age < 50 years, experience of fewer than five cases, and carcinoid/gastrointestinal stromal tumour or scar histology., Conclusion: Operative efficiency appears to improve as surgeons completed 16 TEM cases. We have identified important factors that result in longer operating time. The study has important implications with regard to surgical training and operative planning for new TEM programmes., (Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.)

Objective: Health care resources are costly and should be used judiciously and efficiently. Predicting the duration of surgical procedures is key to optimizing operating room resources. Our objective was to identify factors influencing operative time, particularly surgical team turnover., Methods: We performed a single-institution, retrospective review of lobectomy operations. Univariate and multivariate analyses were performed to evaluate the impact of different factors on surgical time (skin-to-skin) and total procedure time. Staff turnover within the nursing component of the surgical team was defined as the number of instances any nurse had to leave the operating room over the total number of nurses involved in the operation., Results: A total of 235 lobectomies were performed by 5 surgeons, most commonly for lung cancer (95%). On multivariate analysis, percent forced expiratory volume in 1 second, surgical approach, and lesion size had a significant effect on surgical time. Nursing turnover was associated with a significant increase in surgical time (53.7 minutes; 95% confidence interval, 6.4-101; P = .026) and total procedure time (83.2 minutes; 95% confidence interval, 30.1-136.2; P = .002)., Conclusions: Active management of surgical team turnover may be an opportunity to improve operating room efficiency when the surgical team is engaged in a major pulmonary resection., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: It is generally accepted that surgical training is associated with increased surgical duration. The purpose of this study was to determine the magnitude of this increase for common surgical procedures by comparing surgery duration in teaching and nonteaching hospitals., Methods: This retrospective population-based cohort study included all adult residents of Ontario, Canada, who underwent 1 of 14 surgical procedures between 2002 and 2012. We used several linked administrative databases to identify the study cohort in addition to patient-, surgeon- and procedure-related variables. We determined surgery duration using anesthesiology billing records. Negative binomial regression was used to model the association between teaching versus nonteaching hospital status and surgery duration., Results: Of the 713 573 surgical cases included in this study, 20.8% were performed in a teaching hospital. For each procedure, the mean surgery duration was significantly longer for teaching hospitals, with differences ranging from 5 to 62 minutes across individual procedures in unadjusted analyses (all p < 0.001). In regression analysis, procedures performed in teaching hospitals were associated with an overall 22% (95% confidence interval 20%-24%) increase in surgery duration, adjusting for patient-, surgeon- and procedure-related variables as well as the clustering of patients within surgeons and hospitals., Conclusion: Our results show that a wide range of surgical procedures require significantly more time to perform in teaching than nonteaching hospitals. Given the magnitude of this difference, the impact of surgical training on health care costs and clinical outcomes should be a priority for future studies.

Background: Contemporaneous trends in cerebral protection during aortic arch surgery include moderate hypothermia (22°C-28°C) and continuous antegrade cerebral perfusion (ACP). Innominate artery cannulation is a simplified, alternative route for ACP; however, clinical outcomes have yet to be evaluated against the gold standard of axillary cannulation., Methods: Between 2008 and 2015, 140 consecutive patients underwent hemiarch reconstruction with moderate hypothermia and continuous ACP at 2 institutions. Axillary cannulation was used in 74 patients (31.1% female, 64.8 ± 12.7 years) and the remaining 66 patients (24.2% female, 60.8 ± 10.5 years) had direct cannulation of the innominate artery for delivery of ACP., Results: Although there were no statistically significant differences in complications, neurological events were almost twice as frequent in innominate (19.7%) than in axillary (10.8%; P = 0.142) whereas prolonged mechanical ventilation was much more common with axillary (17.6%) vs innominate (7.6%; P = 0.078). There were no mortalities in the axillary group and 1 in the innominate group (0% vs 1.5%; P > 0.471) and no statistically significant differences in any other postoperative complications or hospital length of stay. There was a reduction in total operating room time in the innominate group (axillary 454 ± 115 minutes, innominate 318 ± 125 minutes; P < 0.001), and in the matched subgroup analysis of patients who underwent Bentall and hemiarch reconstruction (axillary 456 ± 109 minutes, innominate 370 ± 106 minutes; P = 0.003)., Conclusions: Axillary and innominate artery cannulation for ACP during proximal aortic arch reconstructive surgery resulted in similarly excellent neurological outcomes. Innominate artery cannulation might reduce total surgical time. Possible clinically relevant differences in neurological and respiratory complications require assessment in randomized controlled trials., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The effect of surgical wait times on survival in patients with non-small cell lung cancer (NSCLC) remains largely unknown. Our objective was to determine the effect of surgical wait time on survival and incidence of upstaging in patients with stage I and II NSCLC., Methods: All patients with clinical stage I and II NSCLC who underwent surgical resection in a single centre between January 2010 and December 2011 were reviewed. Analysis was stratified based on preoperative clinical stage. We assessed the effect of wait time on survival using a Cox proportional hazard model with wait time in months as a categorical variable. Incidence of upstaging at least 1 stage was assessed using logistic regression., Results: We identified 222 patients: 180 were stage I and 42 were stage II. For stage I, wait times up to 4 months had no significant effect on survival or incidence of upstaging. For stage II, patients waiting between 2 and 3 months had significantly decreased survival (hazard ratio 3.6, p = 0.036) and increased incidence of upstaging (odds ratio 2.0, p = 0.020) than those waiting 0 to 1 month. For those waiting between 1 and 2 months, there was no significant difference in survival or upstaging., Conclusion: We did not identify an effect of wait time up to 4 months on survival or upstaging for patients with stage I NSCLC. For patients with stage II disease, wait times greater than 2 months adversely affected survival and upstaging.

Purpose: To prospectively compare radiologically created pigtail gastrostomy (PG), in which the tube is inserted directly through the abdominal wall, versus peroral image-guided gastrostomy (POG), in which the tube is inserted through the mouth. Pain profiles (primary outcome measure), fluoroscopy times, total room times, technical success, complications, and quality of life (QOL) were measured., Materials and Methods: Sixty patients were prospectively randomized to receive 14-F PG or 20-F POG tubes. All patients received prophylactically created gastrostomies before radiation therapy for head and neck squamous-cell carcinoma. Patients receiving palliative treatment were excluded, as were those with established pharyngeal obstruction. Pain was measured by numeric rating scale (NRS) scores for 6 weeks after the procedure and by intraprocedural fentanyl and midazolam doses and postprocedural 24-h morphine doses. Fluoroscopy times, total room times, technical success, complications up to 6 months, and gastrostomy-related QOL (using the Functional Assessment of Cancer Therapy-Enteral Feeding questionnaire) were determined., Results: Fifty-six patients underwent the randomized procedure. The POG group required significantly higher intraprocedural midazolam and fentanyl doses (mean, 1.2 mg and 67 μg, respectively, for PG vs 1.9 mg and 105 μg for POG; P < .001) and had significantly longer fluoroscopy times (mean, 1.3 min for PG vs 4.8 min for POG; P < .0001). NRS scores, morphine doses, total room times, technical success, complication rates, and QOL did not differ significantly between groups. The one major complication, a misplaced PG in the peritoneal cavity, followed a technical failure of POG creation., Conclusions: Despite the differences in insertion technique and tube caliber, the measured outcomes of POG and PG are comparable., (Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.)

Introduction: There are limited comparative data on catheter ablation of atrial fibrillation (CAAF) using the second-generation cryoballoon (CB-2) versus point-by-point radiofrequency (RF). This study examines the acute/long-term CAAF outcomes using these 2 strategies., Methods and Results: In this multicenter, retrospective, nonrandomized analysis, procedural and clinical outcomes of 1,196 patients (76% with paroxysmal AF) undergoing CAAF using CB-2 (n = 773) and open-irrigated, non-force sensing RF (n = 423) were evaluated. Pulmonary vein isolation was achieved in 98% with CB-2 and 99% with RF (P = 0.168). CB-2 was associated with shorter ablation time (40 ± 14 min vs. 66 ± 26 min; P < 0.001) and procedure time (145 ± 49 minutes vs. 188 ± 42 minutes; P < 0.001), but greater fluoroscopic utilization (29 ± 13 minutes vs. 23 ± 14 minutes; P < 0.001). While transient (7.6% vs. 0%; P < 0.001) and persistent (1.2% vs. 0%; P = 0.026) phrenic nerve palsy occurred exclusively with CB-2, other adverse event rates were similar between CB-2 (1.6%) and RF (2.6%); P = 0.207. However, freedom from AF/atrial flutter/tachycardia at 12 months following a single procedure without antiarrhythmic therapy was greater with CB-2 (76.6%) versus RF (60.4%); P < 0.001. While this difference was evident in patients with paroxysmal AF (P < 0.001), it did not reach significance in those with persistent AF (P = 0.089). Additionally, CB-2 was associated with reduced long-term need for antiarrhythmic therapy (16.7% vs. 22.0%; P = 0.024) and repeat ablations (14.6% vs. 24.1%; P < 0.001)., Conclusion: In this multicenter, retrospective, nonrandomized study, CAAF using CB-2 coupled with RF as occasionally required was associated with greater freedom from atrial arrhythmias at 12 months following a single procedure without antiarrhythmic therapy when compared to open-irrigated, non-force sensing RF, alone., (© 2015 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals, Inc.)

Background: Combined pancreaticoduodenectomy (PD) and colonic resection may be necessary to achieve an R0 resection of peri-ampullary tumours. The aim of this study was to examine the morbidity and mortality associated with this procedure., Methods: A retrospective cohort study was performed comparing 607 patients who underwent a standard pancreaticoduodenectomy (S-PD) to 28 patients who had a concomitant colon resection and PD (PD-colon) over a 10-year period at an academic centre., Results: Patients in the PD-colon group were more likely to have received neoadjuvant chemotherapy ± radiation (3/28, 11% versus 14/607, 2%, P = 0.024). Operative time was also longer (530 versus 410 min, P < 0.001) and they were more likely to have had portal vein resections (9/28, 32% versus 76/607, 13%, P = 0.007). There was no difference in the intra-operative blood loss, length of stay, or overall complication rates. The PD-colon group had a higher rate of severe post-operative bleeding (4/28, 11% versus 8/607, 1%, P = 0.002). The post-operative mortality rates for the PD-colon and PD groups were 2/28 (7%) and 8/607 (1%), respectively (P = 0.068)., Conclusions: PD-colon has an acceptable risk of peri-operative morbidity compared with S-PD in well-selected patients., (© 2014 International Hepato-Pancreato-Biliary Association.)

Purpose: The primary objectives of this historical case-control study were to evaluate the incidence of and reasons and risk factors for adult unanticipated admissions in three tertiary care Canadian hospitals following ambulatory surgery., Methods: A random sample of 200 patients requiring admission (cases) and 200 patients not requiring admission (controls) was taken from 20,657 ambulatory procedures was identified and compared. The following variables were included: demographics, reason for admission, type of anesthesia, surgical procedure, length of procedure, American Society of Anesthesiologists' (ASA) classification, surgical completion time, pre-anesthesia clinic, medical history, medications (classes), and perioperative complications. Multiple logistic regression analysis was used to assess factors associated with unanticipated admissions., Results: The incidence of unanticipated admission following ambulatory surgery was 2.67%. The most common reasons for admission were surgical (40%), anesthetic (20%), and medical (19%). The following factors were found to be associated with an increased risk of unanticipated admission: length of surgery of one to three hours (odds ratio [OR] 16.70; 95% confidence interval [CI] 4.10 to 67.99) and length of surgery more than three hours (OR 4.26; 95% CI 2.40 to 7.55); ASA class III (OR 4.60; 95% CI 1.81 to 11.68); ASA class IV (OR 6.51; 95% CI 1.66 to 25.59); advanced age (> 80 yr) (OR 5.41; 95% CI 1.54 to 19.01); and body mass index (BMI) of 30-35 (OR 2.81; 95% CI 1.31 to 6.04). Current smoking status was found to be associated with a decreased likelihood of unanticipated admission (OR 0.44; 95% CI 0.23 to 0.83), as was monitored anesthesia care when compared with general anesthesia (OR 0.17; 95% CI 0.04 to 0.68) and plastic (OR 0.18; 95% CI 0.07 to 0.50), orthopedic (OR 0.16; 95% CI 0.08 to 0.33), and dental/ear-nose-throat surgery (OR 0.32; 95% CI 0.13 to 0.83) when compared with general surgery. Other comorbid conditions did not impact unanticipated admission., Conclusion: Unanticipated admission after ambulatory surgery occurs mainly due to surgical, anesthetic, and medical complications. Length of surgery more than one hour, high ASA class, advanced age, and increased BMI were all predictors. No specific comorbid illness was associated with an increased likelihood of unanticipated admission. These findings support continued use of the ASA classification as a marker of patient perioperative risk rather than attributing risk to a specific disease process.

Purpose: To investigate whether tracheostomy increases the risk of sternal wound infection (SWI) post cardiac surgery., Methods: All patients undergoing cardiac surgery via median sternotomy from September 1997 to October 2010 were included in this retrospective observational study. Primary exposure was tracheostomy performed during admission to the cardiac surgical intensive care unit. The primary outcome was SWI during hospital admission. Multivariable logistic regression was used to determine if tracheostomy was an independent predictor of SWI. Restriction and propensity score analyses were then used to assess if tracheostomy is a causal risk factor for SWI., Results: Four hundred and eleven of 18,845 patients (2.2%) were treated with tracheostomy. Incidences of SWI in tracheostomy and non-tracheostomy groups were 19.5% (80/411) and 0.8% (154/18,434), respectively. Using multivariable logistic regression analysis, tracheostomy was found to be an independent predictor of SWI (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.9 to 4.2). In an analysis restricted to respiratory failure patients, tracheostomy was associated with sternal wound infection (OR 3.4; 95% CI 2.4 to 4.9). When the analysis was stratified by the risk of receiving tracheostomy as represented by propensity score (PS), 46 patients (12%) in the intermediate risk category (PS 0.2-0.4) had SWIs (adjusted OR 2.97; 95% CI 1.6 to 5.6), and 52 patients (14%) in the highest risk category (PS > 0.4) had SWIs (OR 1.52; 95% CI 0.85 to 2.87)., Discussion: Our single-centre observational study of cardiac surgery patients found tracheostomy to be an independent risk factor for SWI. Our analysis showed a robust association when restricted to patients with respiratory failure and after the population was stratified by the propensity to have a tracheostomy.