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Background: Patients who require emergency general surgery (EGS) are at a substantially higher risk for perioperative morbidity and mortality than patients undergoing elective general surgery. The acute care surgery (ACS) model has been shown to improve EGS patient outcomes and cost-effectiveness. A recent systematic review has shown extensive heterogeneity in the structure of ACS models worldwide. The objective of this study was to describe the current landscape of ACS models in academic centres across Canada. Methods: We sent an online questionnaire to the 18 academic centres in Canada. The lead ACS physicians from each institution completed the questionnaire, describing the structure of their ACS models. Results: In total, 16 institutions responded, all of which reported having ACS models, with a total of 29 ACS services described. All services had resident coverage. Of the 29, 18 (62%) had dedicated allied health care staff. The staff surgeon was free from elective duties while covering ACS in 17/29 (59%) services. More than half (15/29; 52%) of the services described protected ACS operating room time, but only 7/15 (47%) had a dedicated ACS room all 5 weekdays. Four of 29 services (14%) had no protected ACS operating room time. Only 1/16 (6%) institutions reported a mandate to conduct ACS research, while 12/16 (75%) found ACS research difficult, owing to lack of resources. Conclusion: We saw large variations in the structure of ACS models in academic centres in Canada. The components of ACS models that are most important to patient outcomes remain poorly defined. Future research will focus on defining the necessary cornerstones of ACS models. Contexte: Les personnes qui ont besoin d'une chirurgie g n rale d'urgence (CGU) sont expos es un risque nettement plus lev de morbidit et de mortalit p riop ratoires comparativement aux personnes soumises une chirurgie g n rale non urgente. Il a t d montr que le mod le de chirurgie en soins actifs (CSA) am liore le rapport co t-efficacit et les r sultats pour les personnes soumises une CGU. Selon une r cente revue syst matique, la structure des mod les de CSA est tr s h t rog ne dans le monde. L'objectif de cette tude tait de d crire le paysage actuel des mod les de CSA dans les centres hospitaliers universitaires au Canada. M thodes: Nous avons fait parvenir un questionnaire en ligne aux 18 centres hospitaliers universitaires canadiens. Les m decins responsables des services de CSA de chaque tablissement ont r pondu au questionnaire et ont d crit la structure de leurs mod les de CSA. R sultats: En tout, 16 tablissements ont r pondu et tous ont indiqu qu'ils disposent de mod les de CSA; 29 services de CSA ont ainsi t d crits. Des m decins r sidents assuraient la couverture de tous ces services. Sur les 29 services de CSA, 18 (62%) disposaient d'une quipe soignante d di e. La chirurgienne ou le chirurgien en poste tait relev de ses fonctions non urgentes pendant sa couverture des services de CSA dans 17 services sur 29 (59%). Plus de la moiti (52%) des services ont d clar r server du temps pour la CSA au bloc op ratoire, mais seulement 7 sur 15 (47%) disposaient d'un bloc op ratoire r serv la CSA du lundi au vendredi. Quatre services sur 29 (14%) ne disposaient pas de temps r serv au bloc op ratoire pour la CSA. Un seul tablissement sur 16 (6%) s'est fait confier le mandat de faire de la recherche sur la CSA, tandis que 12 sur 16 (75%) ont d plor un manque de ressources, ce qui rend la recherche sur la CSA difficile. Conclusion: Nous avons observ une grande h t rog n it structurale entre les diff rents mod les de CSA appliqu s dans les centres hospitaliers universitaires canadiens et leurs l ments les plus importants pour les r sultats chez les patients demeurent mal d finis. La recherche devra se poursuivre sur les aspects incontournables des mod les de CSA., Patients who require emergency general surgery (EGS) represent a high-risk population, often with severe physiologic derangements, and require urgent timely intervention to prevent deterioration of their condition, including death. (1-3) [...]

Background: Access to the operating room (OR) is variable among emergency general surgery (EGS) services, with some having dedicated EGS ORs, and others only a shared queue. Currently in Canada, only a limited number of acute care surgery services have dedicated daytime operating room (OR) access; hence, we aimed to describe the burden of after-hours EGS operating in Canada and differences associated with OR access. Methods: In this multicentre retrospective cohort study, we used data from a previously conducted study designed to evaluate nonappendiceal, nonbiliary disease across 8 Canadian hospitals. We performed a secondary analysis to describe booking priorities and timing of operative interventions, compare sites with and without access to a dedicated EGS daytime OR, and identify differences in morbidity and mortality based on timing of operative intervention. Results: Among 1244 patients, operations were performed during weekday daytime in 521 cases (41.9%), in the evening in 279 (22.4%), on the weekend in 293 (23.6%) and overnight in 151 (12.1%). Operating room booking priority was more than 2 hours to 8 hours in 657 cases (52.8%), more than 8 hours to 24 hours in 334 (26.9%) and more than 24 hours to 48 hours in 253 (20.3%). Substantial variation in booking priority was observed for the same preoperative diagnoses. Sites with dedicated EGS ORs performed a greater proportion of cases during daytime versus overnight compared to sites without dedicated EGS ORs (198/237 [83.5%] v. 323/435 [74.2%], p = 0.006). No significant differences in outcome were found between cases performed during the daytime, evening and overnight. Conclusion: We found considerable variation in OR booking priority within the same preoperative diagnoses among EGS patients in Canada. Sites with dedicated EGS ORs performed more cases during weekday daytime compared to sites without dedicated EGS ORs; however, this study showed no evidence of compromised outcomes based on OR timing. Contexte : Tous les services de chirurgie générale d'urgence (CGU) n'ont pas le même accès aux blocs opératoires (BO). Certains ont des BO dédiés, d'autres doivent se placer dans une file d'attente partagée. ?€ l'heure actuelle, au Canada, seul un nombre limité de services de chirurgie d'urgence disposent de BO dédiés accessibles durant le jour. Nous avons donc voulu décrire le fardeau imposé aux services de CGU qui doivent opérer en dehors des heures régulières au Canada et les différences d'accès aux BO. Méthodes : Dans cette étude de cohorte multicentrique rétrospective, nous avons utilisé les données d'une étude précédente qui a porté sur des cas non liés à l'appendicite ou à la cholécystite dans 8 hôpitaux canadiens. Nous avons procédé à une analyse secondaire afin de décrire les priorités d'inscription et le moment des chirurgies, comparer les établissements pourvus ou non d'un accès à des BO dédiés pour les CGU durant le jour, et établir les différences de morbidité et de mortalité selon le moment des interventions. Résultats : Sur un total de 1244 cas, les opérations ont été effectuées un jour de semaine et durant le jour dans 521 cas (41,9 %), le soir dans 279 cas (22,4 %), un jour de fin de semaine dans 293 cas (23,6 %) et la nuit dans 151 cas (12,1 %). La priorité d'inscription aux BO était de plus de 2 heures à 8 heures dans 657 cas (52,8 %), de plus de 8 heures à 24 heures dans 334 cas (26,9 %) et de plus de 24 heures à 48 heures dans 253 cas (20,3 %). On a observé une variation substantielle des priorités d'inscription pour de mêmes diagnostics préopératoires. Les hôpitaux pourvus de BO dédiés pour les CGU ont pris en charge un plus grand nombre de cas durant le jour plutôt que la nuit, comparativement aux établissements dépourvus de BO dédiés aux CGU (198/237 [83,5 %] c. 323/435 [74,2 %], p = 0,006). On n'a observé aucune différence en ce qui concerne l'issue des interventions selon qu'elles avaient eu lieu le jour, le soir ou la nuit. Conclusion : Nous avons constaté une variation substantielle des priorités d'inscription aux BO pour les mêmes diagnostics préopératoires dans les cas de CGU au Canada. Les établissements pourvus de BO dédiés pour les CGU ont opéré un plus grand nombre de cas les jours de semaine durant le jour que les établissements dépourvus de BO dédiés aux CGU; par contre, cette étude n'a mis au jour aucune complication associée au moment d'utilisation des BO., Despite widespread implementation of the acute care surgery (ACS) model, after-hours emergency general surgery (EGS) care accounts for a sizeable proportion of the ACS workload in Canada. Although the ACS [...]

IntroductionOver the last 5 years, the American Association for the Surgery of Trauma has developed grading scales for emergency general surgery (EGS) diseases. In a previous validation study using diverticulitis, the grading scales were predictive of complications and length of stay. As EGS encompasses diverse diseases, the purpose of this study was to validate the grading scale concept against a different disease process with a higher associated mortality. We hypothesized that the grading scale would be predictive of complications, length of stay, and mortality in skin and soft-tissue infections (STIs).MethodsThis multi-institutional trial encompassed 12 centers. Data collected included demographic variables, disease characteristics, and outcomes such as mortality, overall complications, and hospital and ICU length of stay. The EGS scale for STI was used to grade each infection and two surgeons graded each case to evaluate inter-rater reliability.Results1170 patients were included in this study. Inter-rater reliability was moderate (kappa coefficient 0.472-0.642, with 64-76% agreement). Higher grades (IV and V) corresponded to significantly higher Laboratory Risk Indicator for Necrotizing Fasciitis scores when compared with lower EGS grades. Patients with grade IV and V STI had significantly increased odds of all complications, as well as ICU and overall length of stay. These associations remained significant in logistic regression controlling for age, gender, comorbidities, mental status, and hospital-level volume. Grade V disease was significantly associated with mortality as well.ConclusionThis validation effort demonstrates that grade IV and V STI are significantly predictive of complications, hospital length of stay, and mortality. Though predictive ability does not improve linearly with STI grade, this is consistent with the clinical disease process in which lower grades represent cellulitis and abscess and higher grades are invasive infections. This second validation study confirms the EGS grading scale as predictive, and easily used, in disparate disease processes.Level of evidencePrognostic/Epidemiologic retrospective multicenter trial, level III.

Background: The risk of death after a postoperative complication--known as failure to rescue (FTR)--has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres. Methods: In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit). Results: A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment. Conclusion: There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services. Contexte : On a propose que le risque de deces apres une complication postoperatoire--appele << echec de sauvetage >>--pourrait s'averer une mesure plus pertinente de la qualite du systeme de sante que les indicateurs comparatifs traditionnels, comme les taux de complications et de mortalite. Cette etude visait a determiner le taux reel d'echec de sauvetage dans les centres de chirurgies generales d'urgence (CGU) au Canada. Notre hypothese etait que ce taux varie grandement d'un centre a l'autre. Methodes : Dans le cadre de cette etude de cohorte retrospective multicentrique, nous avons realise une analyse secondaire des donnees issues d'une etude anterieure, dont l'objectif etait d'evaluer les interventions chirurgicales relatives a des atteintes ne touchant ni l'appendice ni la vesicule biliaire effectuees par 6 centres de CGU au Canada (1 en Colombie-Britannique, 1 en Alberta, 3 en Ontario et 1 en Nouvelle-Ecosse). Ces interventions ont eu lieu du 1er janvier au 31 decembre 2014. Nous avons compare les 2 categories de patients--avec complications et sans complications--au moyen d'analyses univariees. Nous avons aussi mene une analyse de sensibilite con-cernant le taux de mortalite apres des complications graves (3 ou 4 selon la classification de Clavien-Dindo) qui ont necessite une intervention chirurgicale ou des soins specialises (par exemple, une admission en soins intensifs). Resultats : L'etude a porte sur un total de 2595 patients. Sur les 206 patients decedes dans les 30 jours, 145 (70,4 %) ont eu une complication avant leur deces. Globalement, le taux de mortalite apres une complication postoperatoire (soit le taux d'echec de sauvetage) etait de 16,0 %. Le classement des centres avec les indicateurs traditionnels (taux de complications et de mortalite) n'etait pas le meme une fois pris en compte le taux d'echec de sauvetage. Conclusion : Le taux d'echec de sauvetage varie d'un centre de CGU a l'autre au pays, ce qui laisse croire qu'une amelioration continue de la qualite reste possible. Cette etude fournit des donnees de reference sur les taux d'echec de sauvetage aux centres de CGU au Canada., Emergency general surgery (EGS) conditions present a substantial health care burden, accounting for 7% of all hospital admissions in the United States. (1) About 25% of patients admitted with an [...]

Lessons learnedThe addition of the heat shock protein 27 (Hsp27)-targeting antisense oligonucleotide, apatorsen, to a standard first-line chemotherapy regimen did not result in improved survival in unselected patients with metastatic pancreatic cancer.Findings from this trial hint at the possible prognostic and predictive value of serum Hsp27 that may warrant further investigation.BackgroundThis randomized, double-blinded, phase II trial evaluated the efficacy of gemcitabine/nab-paclitaxel plus either apatorsen, an antisense oligonucleotide targeting heat shock protein 27 (Hsp27) mRNA, or placebo in patients with metastatic pancreatic cancer.MethodsPatients were randomized 1:1 to Arm A (gemcitabine/nab-paclitaxel plus apatorsen) or Arm B (gemcitabine/nab-paclitaxel plus placebo). Treatment was administered in 28-day cycles, with restaging every 2 cycles, until progression or intolerable toxicity. Serum Hsp27 levels were analyzed at baseline and on treatment. The primary endpoint was overall survival (OS).ResultsOne hundred thirty-two patients were enrolled, 66 per arm. Cytopenias and fatigue were the most frequent grade 3/4 treatment-related adverse events for both arms. Median progression-free survival (PFS) and OS were 2.7 and 5.3 months, respectively, for arm A, and 3.8 and 6.9 months, respectively, for arm B. Objective response rate was 18% for both arms. Patients with high serum level of Hsp27 represented a poor-prognosis subgroup who may have derived modest benefit from addition of apatorsen.ConclusionAddition of apatorsen to chemotherapy does not improve outcomes in unselected patients with metastatic pancreatic cancer in the first-line setting, although a trend toward prolonged PFS and OS in patients with high baseline serum Hsp27 suggests this therapy may warrant further evaluation in this subgroup.

Background: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. Methods: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged > 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. Results: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11 %) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and debridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall in-hospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). Conclusion: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement. Contexte : La plupart des etudes sur les services de chirurgie generate d'urgence (CGU) s'interessent seulement aux atteintes de l'appendice et de la vesicule biliaire. Pourtant, les chirurgiens du domaine traitent beaucoup d'autres problemes complexes. L'objectif de Petude etait de decrire le travail chirurgical associe a ces problemes dans l'ensemble du Canada. Methodes : Notre etude de cohorte retrospective multicentrique inclut les patients adultes ([greater than or equal to] 18 ans) qui ont subi en 2014 une operation non planifiee pour une atteinte qui ne touchait ni l'appendice ni la vesicule biliaire dans 1 des 7 centres selectionnes, repartis un peu part out au pays. Nous avons recueilli les donnees suivantes : renseignements de base des patients, diagnostic, details de l'intervention, nature des complications et duree d'hospitalisation. Puis nous avons degage les facteurs predictifs de morbidite et de mortalite en appliquant un modele de regression logistique. Resultats : L'echantillon totalisait 2595 patients, pour un age median de 60 ans (ecart interquartile 46-73 ans). Les diagnostics principaux les plus courants etaient l'occlusion de l'intestin grele (16%), la hernie (15 %), la tumeur maligne (11 %) et les lesions perianales (9%). Les interventions les plus frequentes etaient la resection de l'intestin (30%), la reparation d'une hernie (15%), le debridement (11 %) et le debridement de tissus mous ou cutanes infectes (10 %). L'operation a eu lieu le soir ou la nuit (entre 17 h et 8 h) dans 47 % des cas. Le taux global de mortalite a l'hopital etait de 8 %. Des complications sont survenues chez 33% des patients, dont les facteurs predictifs independants etaient Page avance (p = 0,001), un score ASA (de l'American Society of Anesthesiologists) eleve (p = 0,02) et le transfert a partir d'un autre centre (p = 0,001). Conclusion : Cette etude dresse le profil epidemiologique des interventions effectuees par les services de CGU du Canada en presence d'atteintes autres que celles de l'appendice et de la vesicule biliaire. Les chirurgiens du pays font beaucoup d'interventions generates urgent es, pour traiter des affections associees a un risque eleve de morbidite et de mortalite. Les resultats de Petude guideront les prochaines recherches et serviront de points de reference en matiere d'amelioration de la qualite., Emergency general surgery (EGS) is associated with a tremendous burden of disease. In the United States, EGS admissions represent 7% of all hospital admissions, and in 2010 they cost the [...]

Background: There is limited literature on the risk of venous thromboembolism (VTE) in emergency general surgery (EGS) patients. We undertook this study to identify the rate of symptomatic VTE for patients undergoing EGS operations. Methods: We conducted a retrospective cohort study evaluating EGS patients who underwent operative intervention between March and December 2014. Data collected included patient demographics, type of procedure, risk of VTE, VTE prophylaxis, development of symptomatic VTE, and mortality. Results: We included 767 patients in our analysis. The mean age was 53 [+ or -] 19.7 years, and 52.2% of patients were female. Eighteen patients (2.3%) experienced VTE in hospital and 12 (1.6%) experienced VTE after discharge. Only 66% of patients received appropriate VTE prophylaxis. High-risk patients had a higher VTE rate (7.4% v. 2.3%, p < 0.001) and higher mortality (17.6% v. 4.0%, p < 0.001) than lowto moderate-risk patients. Conclusion: The risk of VTE in patients requiring EGS is significant and persists after hospital discharge. Further studies on quality improvement with VTE prophylaxis are warranted. Contexte : La litterature sur le risque de thromboembolie veineuse (TEV) chez les patients soumis a une chirurgie generale urgente est limitee. Nous avons entrepris cette etude afin de mesurer le taux de TEV symptomatique chez les patients ayant subi une intervention urgente en chirurgie generale. Methodes : Nous avons procede a une etude de cohorte retrospective sur les patients qui ont subi une chirurgie generale urgente entre mars et decembre 2014. Parmi les donnees recueillies, mentionnons donnees demographiques, type d'intervention, risque de TEV, thromboprophylaxie, apparition d'une TEV symptomatique et mortalite. Resultats : Nous avons inclus 767 patients dans notre analyse. L'age moyen etait de 53 [+ or -] 19,7 ans et 52,2 % des patients etaient de sexe feminin. Dix-huit patients (2,3 %) ont presente une TEV en cours d'hospitalisation et 12 (1,6 %) apres leur conge. Seulement 66 % des patients ont recu une thromboprophylaxie adequate. Les patients a haut risque ont presente des taux de TEV (7,4 % c. 2,3 %, p < 0,001) et de mortalite (17,6 % c. 4,0 %, p < 0,001) plus eleves que les patients presentant un risque faible a modere. Conclusion : Le risque de TEV chez les patients soumis a une chirurgie generale urgente est significatif et persiste apres le conge hospitalier. Il faudra mener des etudes plus approfondies sur l'amelioration de la qualite de la thromboprophylaxie., The reported incidence of venous thromboembolism (VTE) has been on the rise. There is significant morbidity and mortality associated with the development of VTE, including prolonged hospital admission, risk of [...]