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This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence.Cette déclaration de consensus fait des recommandations pour la prescription d'analgésiques à la sortie de l'hôpital pour les patients adultes n'ayant jamais pris d'opiacés et qui subissent une intervention chirurgicale non urgente. Elle encourage les prestataires de soins de santé (chirurgiens, anesthésiologistes, infirmières et infirmiers, infirmières et infirmiers praticiens, équipes antidouleur, pharmaciens, professionnels de la santé et stagiaires) à (1) utiliser des traitements non opiacés et à réduire la prescription d'opiacés afin de réduire le nombre de pilules opiacées pouvant être détournées; et (2) à éduquer les patients, ainsi que leurs familles et soignants, sur les options de prise en charge de la douleur après l'opération afin d'optimiser la qualité des soins pour la douleur postopératoire.Ces recommandations s'appliquent aux patients adultes n'ayant jamais pris d'opioïdes et qui subissent une intervention chirurgicale non urgente. Cette déclaration de consensus est destinée à être utilisée par les prestataires de soins de santé impliqués dans la prise en charge des patients opérés et les soins qui leur sont apportés.Un processus Delphi modifié a été utilisé pour parvenir à un consensus sur les recommandations. Tout d'abord, les auteurs ont procédé à une de la portée de la littérature afin de déterminer les pratiques exemplaires actuelles et les lignes directrices existantes. À partir de la littérature disponible et de l'expertise des auteurs, une liste provisoire de recommandations a été créée. Ensuite, les auteurs ont demandé aux principales parties prenantes d'examiner et de commenter plusieurs versions préliminaires du document et d'assister à une réunion de consensus en personne. Le groupe des parties prenantes du processus Delphi modifié comprenait des chirurgiens, des anesthésiologistes, des résidents, des fellows, des infirmières et infirmiers, des pharmaciens et des patients. Après de multiples itérations, le document a été jugé complet. Les recommandations n'ont pas été notées car elles étaient fondées sur un consensus plutôt que sur des données probantes.

The extreme disturbances caused by the COVID -19 pandemic on our academic medical centers compounded by a recurrent surge of violence against people of color have reopened our wounds exposing fragility, inequality, and continued racial disparities in society and health. At the center of this severe institutional disruption, leaders will be compelled to take action to keep their constituents and patients safe and their hospitals and departments afloat during and after a pandemic, all while simultaneously addressing and implementing the cultural changes required to eliminate systemic racism and discrimination. Organizational disruptions of this magnitude will naturally test one's principles, loyalties and responsibilities while challenging the practical burdens of leadership. If the goal of responding to these upheavals is to bring them to resolution and ultimately to bring about organizational change for the better, ethical leadership is critical. Applying ethical principles allows leaders to chart clear paths to solutions both in the short and long term. We review the principles of ethical leadership exemplified by a case illustration and provide a novel resource to help ensure ethical leadership in academic medicine and beyond.

Gastrointestinal cancer surgery patients often develop perioperative anemia commonly treated with red blood cell (RBC) transfusions. Given the potential associated risks, evidence published over the past 10 years supports restrictive transfusion practices and blood conservation programs. Whether transfusion practices have changed remains unclear. We describe temporal RBC transfusion trends in a large North American population who underwent gastrointestinal cancer surgery. We conducted a population-based retrospective cohort study of patients who underwent gastrointestinal cancer resection between 2007 and 2018 using health administrative datasets. The outcome was RBC transfusion during hospitalization. Temporal transfusion trends were analyzed with Cochran-Armitage tests. Multivariable regression assessed the association between year of diagnosis and likelihood of RBC transfusion while controlling for confounding. Of 79,764 patients undergoing gastrointestinal cancer resection, the median age was 69 years old (interquartile range (IQR) 60–78 years) and 55.5% were male. The most frequent procedures were colectomy (52.8%) and proctectomy (23.0%). A total of 18,175 patients (23%) received RBC transfusion. The proportion of patients transfused decreased from 26.5% in 2007 to 18.9% in 2018 (p

Summary The Canadian Association of General Surgeons (CAGS) Board of Directors hosted a symposium to develop a Canadian strategy for surgical quality and safety at its mid-term meeting on Feb. 24, 2018. The following 6 principles outline the consensus of this symposium, which included diverse stakeholders and surgeon leaders across Canada: 1) a Canadian quality-improvement strategy for surgery is needed; 2) quality improvement requires continuous, active and intentional effort; 3) outcome measurement alone will not drive improvement; 4) increased focus on standardization and process improvement is necessary; 5) new, large electronic medical record systems pose challenges as well as benefits in Canadian hospitals; and 6) surgeons in remote and rural hospitals must be engaged using tailored approaches.

Most often researchers study the effectiveness of new treatments, and assessment of harm (side effects) is a secondary outcome. In this situation, it is accepted that randomized controlled trials are the best for assessing effectiveness. However, there are some circumstances when the researcher wants to assess the safety of a drug or technology. In this situation, it would be unethical to randomize individuals to treatment groups to determine which intervention is most harmful. Instead, case control or cohort studies are most often used. Case control studies are observational studies which are often used in epidemiology to look at causation. Cohort studies are longitudinal studies in which patients are followed from a defined time but rather than being randomly assigned to a group, the individuals chose the group they are in. Because harmful effects often occur infrequently, these studies tend to include a large number of individuals. Although participants are not randomized, it is still important that there is rigor in the study. Thus, the two groups need to be similar with the exception of the exposure of concern, follow-up must be complete and there should be a temporal and dose response gradient. For the reader, who wants to know whether his patients will be harmed by the intervention, the magnitude and precision of the risk is important. Furthermore, presenting the results as the number needed to harm (NNH) may be of clinical value to the reader. Unlike the number needed to treat, a high number for the NNH is optimal.

Over the course of greater than 40 years we have revised the approach to Kock pouch construction from the original description by Professor Kock in 1969 in an attempt to improve pouch function and reduce the risk of complications and revisions. Over this period, 194 patients have undergone Kock pouch construction and/or revision at our institution, with an estimated 20-year pouch survival of 67%. The most common complication remains valve slippage which may be corrected in approximately half of the patients undergoing revision. Overall, our patients undergoing Kock pouch surgery report an excellent quality of life. We present here a review of the evolution of primary Kock pouch construction at our institution, and a detailed illustrated description of our current operative approach and post-operative care for the Kock pouch.

Numerous reports have documented the effectiveness of Enhanced Recovery after Surgery (ERAS) pathways in improving recovery and decreasing morbidity and length of stay. However, there is also increasing evidence that ERAS

Preoperative preparation is essential in order to optimize outcomes and decrease complications, mortality, and length of stay of the surgical patient. With the adoption of the concept of enhanced recovery after surgery, there is an increased emphasis on the preoperative phase of care recognizing that if patients are in optimal condition preoperatively, they are more likely to recover more quickly postoperatively. Patient education is also an important part of their care as there is also an increased emphasis on self-management in ERAS protocols.

Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement.To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals.A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback.The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events.On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.

Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients.ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow.Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews.Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential.Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

“Our youth now love luxury. They have bad manners, contempt for authority; they show disrespect for their elders” (www.quoteinvestigator.com). Does that sound like one of your senior colleagues complaining about the current residents whom he believes are slackards and do not work as hard as he did as a resident? While that quote has been attributed to Socrates and Plato, in fact, it was written by Kenneth John Freeman in 1907 as part of his Cambridge dissertation. The quote highlights the fact that thinking the next generation is lazy, ill mannered, and generally not as good as the previous generation is not new. In fact, it is a recurring view with each generation believing that the next generation is more privileged than the one before. The term generation is defined as a group of people whose characteristics were shaped and defined by the societal events that occurred during their formative years.While one has to be careful not to stereotype individuals, individuals who are part of a generation often share similar characteristics and values. The most recent generation to enter the work force includes individuals who were born between 1982 and 2002 and is termed “Generation Y” or the “Millenials.” In this talk, I would like to discuss what characterizes this generation and the potential impact they will have on society as whole, the workplace, and health care in particular. In addition, I will discuss howwe as surgeons and educators as well as the SSAT need to understand this generation in order to accommodate their needs and values since they are the largest demographic group since the Baby Boomers and soon will be our successors. This topic seems particularly relevant now as medical and surgical education and health care delivery are undergoing fundamental changes.

BACKGROUND: Comparative outcome data for laparoscopic and open subtotal colectomy in IBD are lacking and often difficult to interpret owing to low case volumes, heterogeneity in case mix, and variation in laparoscopic technique. OBJECTIVE: This study aimed to determine the safety of laparoscopic subtotal colectomy in severe colitis and to determine whether the laparoscopic approach improved short-term outcomes in comparison with the open approach. DESIGN: This was a retrospective cohort study using data from a prospectively maintained clinical database. SETTING: This study was conducted at a single center, Mount Sinai Hospital, Toronto. PATIENTS: All patients undergoing subtotal colectomy for either ulcerative or Crohn's colitis between 2000 and 2011 were included. INTERVENTION: A standardized operative technique was used for both laparoscopic and open subtotal colectomies. Cases performed by non-laparoscopic surgeons were excluded. MAIN OUTCOME MEASURES: Perioperative outcome measures were operative duration, estimated blood loss, total morphine requirement, and length of postoperative stay. Postoperative outcome measures were the rates of minor and major complications. RESULTS: Laparoscopic subtotal colectomies were performed in 131 of 290 cases (45.2%). Nine patients required conversion to an open procedure (6.9%). The uptake of laparoscopic subtotal colectomy increased from 10.2% in 2000/2001 to 71.7% in 2010/2011. Regression analysis with propensity-score adjustment for operative approach revealed that the operative duration was 25.5 minutes longer in laparoscopic cases (95% CI 12.3-38.6; p < 0.001), but that patients experienced fewer minor complications (OR 0.47; 95% CI 0.23-0.96; p = 0.04) and required less morphine (adjusted difference, -72.8 mg; 95% CI 4.9-141; p = 0.04). LIMITATIONS: The inherent selection bias of this retrospective cohort study may not be accounted for by multivariate analysis with propensity-score adjustment. CONCLUSIONS: Laparoscopic subtotal colectomy is safe and may reduce the rate of minor postoperative complications. The increase in operative duration reflects the technical demands associated with this procedure (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A160).

Non-steroidal anti-inflammatory drugs (NSAIDs) decrease postoperative pain and opioid consumption. The objective of the study was to determine if postoperative NSAIDs were associated with anastomotic leaks following elective colorectal surgery. We used a matched nested case-control study design. Using a prospectively collected database, we identified all patients having elective colorectal surgery between January 2001 and June 2012. Cases and matched controls were identified based on the occurrence of a postoperative anastomotic leak. The primary and secondary exposure variables were, respectively, use of any NSAID and use of ketorolac specifically. Conditional logistic regression was used to determine the unadjusted and adjusted odds ratio. A total of 262 patients were included (65.6 % inflammatory bowel disease, 34.4 % cancer). Use of any NSAID was associated with a non-significant increase in anastomotic leaks (odds ratio (OR) 1.81, 95 % confidence interval (CI) 0.98–3.37, p = 0.06). Use of ketorolac was associated with a significant increase in anastomotic leaks (OR 2.09, 95 % CI 1.12–3.89, p = 0.021). There was no significant association between anastomotic leaks and cumulative NSAID dose. These data suggest that there may be an association between NSAIDs and risk of anastomotic leaks after colorectal surgery. Further research is needed to better elucidate this relationship to clarify the implications for patients.

Colorectal cancer physician champions across the province of Ontario, Canada, reported significant concern about appropriate selection of patients for preoperative chemoradiotherapy because of perceived variation in the completeness and consistency of MRI reports.The purpose of this work was to develop, pilot test, and implement a synoptic MRI report for preoperative staging of rectal cancer.This was an integrated knowledge translation project.This study was conducted in Ontario, Canada.Surgeons, radiologists, radiation oncologists, medical oncologists, and pathologists treating patients with rectal cancer were included in this study.A multifaceted knowledge translation strategy was used to develop, pilot test, and implement a synoptic MRI report. This strategy included physician champions, audit and feedback, assessment of barriers, and tailoring to the local context. A radiology webinar was conducted to pilot test the synoptic MRI report.Seventy-three (66%) of 111 Ontario radiologists participated in the radiology webinar and evaluated the synoptic MRI report.A total of 78% and 90% radiologists expressed that the synoptic MRI report was easy to use and included all of the appropriate items; 82% noted that the synoptic MRI report improved the overall quality of their information, and 83% indicated they would consider using this report in their clinical practice. An MRI report audit after implementation of the synoptic MRI report showed a 39% improvement in the completeness of MRI reports and a 37% uptake of the synoptic MRI report format across the province.Radiologists evaluating the synoptic MRI report and participating in the radiology webinar may not be representative of gastroenterologic radiologists in other geographic jurisdictions. The evaluation of completeness and uptake of the synoptic MRI reports is limited because of unmeasured differences that may occur before and after the MRI.A synoptic MRI report for preoperative staging of rectal cancer was successfully developed and pilot tested in the province of Ontario, Canada.

Background: Surgery is a cornerstone of cancer treatment, but significant differences in the quality of surgery have been reported. Surgical process improvement tools (spits) modify the processes of care as a means to quality improvement (qi). We were interested in developing spits in the area of gastrointestinal (gi) cancer surgery. We report the recommendations of an expert panel held to define quality gaps and establish priority areas that would benefit from spits. Methods: The present study used the knowledge-to-action cycle was as a framework. Canadian experts in qi and in gi cancer surgery were assembled in a nominal group workshop. Participants evaluated the merits of spits, described gaps in current knowledge, and identified and ranked processes of care that would benefit from qi. A qualitative analysis of the workshop deliberations using modified grounded theory methods identified major themes. Results: The expert panel consisted of 22 participants. Experts confirmed that spits were an important strategy for qi. The top-rated spits included clinical pathways, electronic information technology, and patient safety tools. The preferred settings for use of spits included preoperative and intraoperative settings and multidisciplinary contexts. Outcomes of interest were cancer-related outcomes, process, and the technical quality of surgery measures. Conclusions: Surgical process improvement tools were confirmed as an important strategy. Expert panel recommendations will be used to guide future research efforts for spits in gi cancer surgery.

Canadian Association of General Surgeons, the American College of Surgeons, the Canadian Society of Colorectal Surgeons, and the American Society of Colorectal Surgeons Evidence Based Reviews in Surgery : Colorectal Surgery

Objective: Defining processes of care, which are appropriate and necessary for management of gastric cancer (GC), is an important step toward improving outcomes. Methods: Using a RAND/UCLA Appropriateness Method, an international multidisciplinary expert panel created 22 statements reflecting optimal management. All statements were scored for appropriateness and necessity. Results: The following tenets were scored appropriate and necessary: (1) preoperative staging by computed tomography of abdomen/pelvis; (2) positron-emission tomographic scans not routinely indicated; (3) consideration for adjuvant therapy; (4) further clinical trials; (5) multidisciplinary decision making; (6) sufficient support at hospitals; (7) assessment of 16 or more lymph nodes (LNs); (8) in metastatic disease, surgery only for palliation of major symptoms; (9) surgeons experienced in GC management; (10) and surgeons experienced in both GC management and advanced laparoscopic surgery for laparoscopic resection. The following were scored appropriate, but of indeterminate necessity: (1) diagnostic laparoscopy before treatment; (2) a multidisciplinary approach to linitis plastica; (3) genetic assessment for diffuse GC and family history, or age less than 45 years; (4) endoscopic removal of select T1aN0 lesions; (5) D2 LN dissection in curative intent cases; (6) D1 LN dissection for early GC or patients with comorbidities; (7) frozen section analysis of margins; (8) nonemergent cases performed in a hospital with a volume of more than 15 resections per year; and (9) by a surgeon with more than 6 resection per year. Conclusions: The expert panel has created 22 statements for the perioperative management of GC patients, to provide guidance to clinicians and improve the care received by patients.

Importance Chemoradiotherapy (CRT), followed by surgery, is the recommended approach for stage II and III rectal cancer. While CRT decreases the risk of local recurrence, it does not improve survival and leads to poorer functional outcomes than surgery alone. Therefore, new approaches to better select patients for CRT are important. Objective To conduct a phase 2 study to evaluate the safety and feasibility of using magnetic resonance imaging (MRI) criteria to select patients with “good prognosis” rectal tumors for primary surgery. Design, Setting, and Participants Prospective nonrandomized phase 2 study at 12 high-volume colorectal surgery centers across Canada. From September 30, 2014, to October 21, 2016, a total of 82 patients were recruited for the study. Participants were patients newly diagnosed as having rectal cancer with MRI-predicted good prognosis rectal cancer. The MRI criteria for good prognosis tumors included distance to the mesorectal fascia greater than 1 mm; definite T2, T2/early T3, or definite T3 with less than 5 mm of extramural depth of invasion; and absent or equivocal extramural venous invasion. Interventions Patients with rectal cancer with MRI-predicted good prognosis tumors underwent primary surgery. Main Outcomes and Measures The primary outcome was the proportion of patients with a positive circumferential resection margin (CRM) rate. Assuming a 10% baseline probability of a positive CRM, a sample size of 75 was estimated to yield a 95% CI of ±6.7%. Results Eighty-two patients (74% male) participated in the study. The median age at the time of surgery was 66 years (range, 37-89 years). Based on MRI, most tumors were midrectal (65% [n = 53]), T2/early T3 (60% [n = 49]), with no suspicious lymph nodes (63% [n = 52]). On final pathology, 91% (n = 75) of tumors were T2 or greater, 29% (n = 24) were node positive, and 59% (n = 48) were stage II or III. The positive CRM rate was 4 of 82 (4.9%; 95% CI, 0.2%-9.6%). Conclusions and Relevance The use of MRI criteria to select patients with good prognosis rectal cancer for primary surgery results in a low rate of positive CRM and suggests that CRT may not be necessary for all patients with stage II and III rectal cancer. Trial Registration ISRCTN.com identifier:ISRCTN05107772

Multidisciplinary cancer conferences (MCCs) facilitate the discussion of appropriate diagnostic and treatment options for an individual cancer patient. In 2007, a study conducted in Ontario found that 52 % of hospitals were able to provide access to MCCs. In 2006, Cancer Care Ontario published minimum standards for MCCs. A framework for measurement was developed to monitor MCCs at the hospital, regional, and provincial level. The objective of this study was to review the results from initial efforts to improve quality and access through a population-based intervention.Data collection was completed prospectively between October to December in 2009, 2010, and 2011. A criterion satisfaction score (CSS) was developed on the basis of indicators including MCC frequency, type of patient case review, the presence of a chair and coordinator, and the attendance of appropriate medical staff members. For each hospital and region, the overall number of MCCs, patients discussed, and CSSs was calculated.Data were available from 13 of 14 regions in 2009 and all 14 regions in 2010 and 2011. The number of MCCs increased from 660 in 2009 to 798 in 2011 (p = 0.06). The number of patients discussed at MCCs increased from 4,695 in 2009 to 5,702 in 2011 (p = 0.22). The CSS scores across the regions improved significantly across 2009-2011 (p0.001).A population-based intervention has been associated with an improvement in access and quality of MCCs.

Evidence-Based Reviews in Surgery (EBRS) is a program developed to teach critical appraisal skills to general surgeons and residents. The purpose of this study was to assess the use of EBRS by general surgery residents across Canada and to assess residents' opinions regarding EBRS and journal clubs.We surveyed postgraduate year 2-5 residents from 15 general surgery programs. Data are presented as percentages and means.A total of 231 residents (58%, mean 56% per program, range 0%-100%) responded: 172 (75%) residents indicated that they know about EBRS and that it is used in their programs. More than 75% of residents who use EBRS agreed or strongly agreed that the EBRS clinical and methodological articles and reviews are relevant. Only 55 residents (24%) indicated that they used EBRS online. Most residents (198 [86%]) attend journal clubs. The most common format is a mandatory meeting held at a special time every month with faculty members with epidemiological and clinical expertise. Residents stated that EBRS articles were used exclusively (13%) or in conjunction with other articles (57%) in their journal clubs. Most respondents (176 of 193 [91%]) stated that journal clubs are very or somewhat valuable to their education.The EBRS program is widely used among general surgery residents across Canada. Although most residents who use EBRS rate it highly, a large proportion are unaware of EBRS online features. Thus, future efforts to increase awareness of EBRS online features and increase its accessibility are required.Le programme de revues factuelles en chirurgie EBRS (Evidence-Based Reviews in Surgery) a été mis au point pour enseigner aux chirurgiens et aux résidents en chirurgie générale les compétences nécessaires pour faire des évaluations critiques. Le but de cette étude était d'analyser l'utilisation des EBRS par les résidents en chirurgie générale au Canada et de leur demander leur opinion au sujet des EBRS et des clubs de lecture.Nous avons interrogé des résidents des années 2 à 5 rattachés à 15 programmes de chirurgie générale. Les données sont présentées sous forme de pourcentages et de moyennes.En tout, 231 résidents (58 %, moyenne de 56 % par programme, intervalle 0 %–100 %) ont répondu : 172 résidents (75 %) ont indiqué qu'ils connaissent les EBRS et que leur programme les utilise. Plus de 75 % des résidents qui utilisent les EBRS se sont dit d'accord ou tout à fait d'accord avec l'énoncé sur la pertinence des articles et revues cliniques et méthodologiques des EBRS. Seulement 55 résidents (24 %) ont dit utiliser les EBRS en ligne. La plupart des résidents (198 [86 %]) participaient à des clubs de lecture. Leur utilisation la plus courante prend la forme d'une réunion obligatoire tenue à un moment particulier tous les mois avec les enseignants de la faculté ayant une expertise épidémiologique et clinique. Les résidents ont indiqué que les EBRS étaient utilisés seuls (13 %) ou avec d'autres articles (57 %) dans leurs clubs de lecture. La plupart des répondants (176 sur 193 [91 %]) ont affirmé que leurs clubs de lecture sont très ou assez utiles pour leur formation.Le programme EBRS est largement utilisé par les résidents en chirurgie générale au Canada. Même si la plupart des résidents qui utilisent les EBRS leur accordent une cote élevée, une forte proportion ignore l'existence des possibilités web des EBRS. Il faudra donc travailler à mieux faire connaître les possibilités offertes par le programme EBRS sur le web et en faciliter l'accès.

The approach for staging gastric adenocarcinoma (GC) has not been well defined, with heterogeneity in the application of staging modalities.Utilizing a RAND/UCLA appropriateness methodology (RAM), a multidisciplinary expert panel of 16 physicians scored 84 GC staging scenarios. Appropriateness was scored from 1 to 9. Median appropriateness scores from 1 to 3 were considered inappropriate, 4-6 uncertain, and 7-9 appropriate. Agreement was reached when 12 or more of 16 panelists scored the scenario similarly. Appropriate scenarios were subsequently scored for necessity.Pretreatment TNM stage determination is necessary. Necessary staging maneuvers include esophagogastroduodenoscopy (EGD); biopsy of the tumor; documentation of tumor size, description, location, distance from gastroesophageal junction (GEJ), and any GEJ, esophageal, or duodenal involvement; if an EGD report is unclear, surgeons should repeat it to confirm tumor location. Pretreatment radiologic assessment should include computed tomography (CT)-abdomen and CT-pelvis, performed with multidetector CT scanners with 5-mm slices. Laparoscopy should be performed before resection of cT3-cT4 lesions or multivisceral resections. Laparoscopy should include inspection of the stomach, diaphragm, liver, and ovaries.Using a RAM, we describe appropriate and necessary staging tests for the pretreatment staging evaluation of GC, as well as how some of these staging maneuvers should be conducted.

Summary: Objective: To determine the effectiveness of medical therapy (including metronidazole, bismuth carbomer enemas, oral probiotic bacteria, butyrate suppositories, and glutamine suppositories) for inducing a response or for maintaining remission in pouchitis. Search strategy: Studies were selected using the MEDLINE data base (1966-December 1997), abstracts from major gastrointestinal meetings, and references from published articles and reviews. Selection criteria: Four randomized controlled trials of medical therapy in adult patients with pouchitis were identified: two placebo controlled trials in active chronic pouchitis; one maintenance of remission trial comparing two active agents in chronic pouchitis; and one placebo-controlled maintenance of remission trial for chronic pouchitis. A single patient "n-of-l" trial for active chronic pouchitis was excluded. Data collection and analysis: Data were extracted by three independent observers based on the intention to treat principle. Extracted data were converted to 2 x 2 tables (response versus no response and medical therapy versus placebo or medical therapy versus medical therapy) and an odds ratio with 95% confidence intervals (0) were determined as described by Cochrane and Mantel and Haenszel. In addition, the absolute risk reduction, relative risk reduction, and number needed to treat were determined. Main results: The odds ratios of inducing a response using oral metronidazole or bismuth carbomer foam enemas compared with placebo in active chronic pouchitis were 12.34 (95% Cl 2.34-64.95) and 1.00 (95% Cl 0.29-3.42), respectively. The odds ratio of maintaining remission in chronic pouchitis for oral probiotic bacteria (VSL-3) compared with placebo was 15.33 (95% Cl 4.5152.14). There was no difference in the odds ratio of inducing symptomatic remission and then maintaining symptomatic remission after discontinuing suppressive medical therapy for chronic pouchitis with glutamine suppositories compared with butyrate suppositories, 2.75 (95% CI 0.48-15.94). Conclusions: Metronidazole is an effective therapy for active chronic pouchitis. Bismuth carbomer foam enemas are not effective therapy for active chronic pouchitis. Oral probiotic therapy with VSL-3 is an effective therapy for maintaining remission in patients with chronic pouchitis in remission. There is no difference in maintenance of symptomatic remission in patients with chronic pouchitis treated with glutamine versus butyrate suppositories, and it is unknown whether glutamine and butyrate are equally effective or ineffective. Additional randomized, double-blind, placebo-controlled, dose-ranging clinical trials are needed to determine the efficacy of empiric medical therapies currently being used in patients with pouchitis. Key Words: Pouchitis-Ulcerative colitis.

This study was designed to elicit end-user opinions regarding the importance and diagnostic accuracy of MRI for T-category, threatened or involved circumferential margin (CRMi), and lymph node involvement (LNi) for preoperative staging of rectal cancer and to determine completeness of MRI reports for these elements on a population based level. The first part of this study was a mailed survey of surgeons, radiation oncologists, and medical oncologists to elicit their opinions regarding the importance and diagnostic accuracy of T-category, CRMi, and LNi on MRI. The second part of the study was an audit of MRI reports issued for pre-operative staging of rectal cancer to assess the completeness of these reports for T-category, CRMi, and LNi. Although T-category, CRMi, and LNi were considered essential by 97, 94, and 77 % of respondents, respectively, the MRI report audit showed that only 40 % of MRI reports captured all of these elements. The majority of end users reported moderate diagnostic accuracy on MRI for T-category and CRMi and low diagnostic accuracy for LNi (52.3, 43, and 48.5 % respectively). Multivariate analysis showed that specialty was the only independent predictor of correct reporting of the diagnostic accuracy for each of the MRI elements. While end users consider T-category, CRMi and LNi essential for preoperative staging of rectal cancer, less than 40 % of MRI reports captured all of these elements. Therefore, strategies to improve communication between radiologists and end users are critical to improve the overall quality of care for rectal cancer patients.

OBJECTIVE. The objective of this article is to explore with a surgical perspective the key radiologic features after common esophageal, gastric, and bariatric procedures. CONCLUSION. An understanding of procedures on the hollow viscera is essential for radiologists at any level. The ability to quickly recognize postoperative anatomy is critical to accurately and efficiently interpret routine imaging studies and to diagnose postoperative complications.

Objective Previous investigations of short-term outcomes after preoperative exposure to biological therapy in inflammatory bowel disease (IBD) were conflicting. The authors aimed to assess postoperative outcomes in patients who underwent abdominal surgery with recent exposure to anti-tumour necrosis factor therapy. Design A retrospective case-control study with detailed matching was performed for subjects with IBD with and without exposure to biologics within 180 days of abdominal surgery. Postoperative outcomes were compared between the groups. Results 473 procedures were reviewed consisting of 195 patients with exposure to biologics and 278 matched controls. There were no significant differences in most postoperative outcomes such as: length of stay, fever (≥38.5°C), urinary tract infection, pneumonia, bacteraemia, readmission, reoperations and mortality. On univariate analysis, procedures on biologics had more wound infections compared with controls (19% vs 11%; p=0.008), but this was not significant in multivariate analysis. Concomitant therapy with biologics and thiopurines was associated with increased frequencies of urinary tract infections (p=0.0007) and wound infections (p=0.0045). Operations performed ≤14 days from last biologic dose had similar rates of infections and other outcomes when compared with those performed within 15–30 days or 31–180 days. Patients with detectable preoperative infliximab levels had similar rates of wound infection compared with those with undetectable levels (3/10 vs 0/9; p=0.21). Conclusion Preoperative treatment with TNF-α antagonists in patients with IBD is not associated with most early postoperative complications. A shorter time interval from last biological dose is not associated with increased postoperative complications. In most cases, surgery should not be delayed, and appropriate biological therapy may be continued perioperatively.

Objective Systematic reviews were performed to assess methods of teaching the evidence-based medicine (EBM) process and determine which format or what components of journal club appear to be most effective in teaching critical appraisal skills to surgical residents and have the highest user satisfaction. Design MEDLINE, Embase, Web of Science, AMED, PsychINFO, PubMed, Cochrane Library, and Google scholar were searched to identify relevant articles. To be included, studies had to provide details about the format of their EBM curriculum or journal club and report on the effectiveness or participant satisfaction. Potentially relevant articles were independently reviewed by 2 authors and data were extracted on separate data forms. Results Seven studies met the inclusion criteria for assessment of teaching EBM and 8 studies (including 3 in the EBM systematic review) met criteria for assessment of journal club format. Overall, study quality was poor. Only 2 studies were randomized controlled trials. Five were before-after studies, which showed significant improvement in critical appraisal skills or statistical knowledge following an EBM course or journal club. The 2 randomized controlled trials (RCTs) compared teaching EBM or critical appraisal skills in lecture format or journal club to online learning. There was no significant difference in mean scores in 1 study whereas the other reported significantly better scores in the journal club format. Four studies reported high participant satisfaction with the EBM course or journal club format. Conclusions There is some evidence that courses with or without the addition of journal clubs lead to improved knowledge of the EBM process although the impact on patient care is unknown. Journal clubs seem to be the preferred way of teaching critical appraisal skills but while some components of journal clubs are favored by participants, it remains unclear which elements are most important for resident learning.

Context.—Synoptic pathology reports increase the completeness of reporting for colorectal cancer. Despite the perceived superiority of specialist reporting, service demands dictate that general pathologists report colorectal cancer specimens in many centers. Objective.—To determine differences in the completeness of rectal cancer reporting between specialist gastrointestinal and nongastrointestinal pathologists in both the narrative and synoptic formats. Design.—Pathology reports from rectal cancer resections performed between 1997 and 2008 were reviewed. A standardized, synoptic report was formally introduced in 2001. Reports were assessed for completeness according to 10 mandatory elements from the College of American Pathologists checklist. Results.—Overall, synoptic reports (n = 315) were more complete than narrative reports (n = 183) for TNM stage, distance to the circumferential radial margin, tumor grade, lymphovascular invasion, extramural venous invasion, perineural invasion, and regional deposits (all P < .01). Compared with those by nonspecialist pathologists, narrative reports by gastrointestinal pathologists were more complete for lymphovascular invasion (59.3% versus 35.9%, P = .02) and extramural venous invasion (70.4% versus 35.9%, P = .001), but there was no difference in completeness once a synoptic report was adopted. Gastrointestinal pathologists tended to report the presence of extramural venous invasion more frequently in both the narrative (18.5% versus 5.1%, P = .01) and synoptic formats (25.5% versus 14.6%, P = .02). Conclusions.—Completeness of reporting, irrespective of subspecialist interest, was dramatically increased by the use of a synoptic report. Improvements in completeness were most pronounced among nongastrointestinal pathologists, enabling them to attain a level of report completeness comparable to that of gastrointestinal pathologists. Further studies are required to determine whether there are actual discrepancies in the detection of prognostic features between specialist gastrointestinal and nongastrointestinal pathologists.

The objective of enhanced recovery after surgery (ERAS) programs is to incorporate strategies into the perioperative care plan to decrease complications, hasten recovery, and shorten hospital stay. This study was designed to determine which ERAS strategies contribute to overall shortened length of hospital stay in patients undergoing elective colorectal surgery in hospitals. A retrospective cohort study of 336 consecutive patients at seven hospitals was performed. Demographic and data on 18 ERAS components identified from a systematic review of the literature were collected. A multiregression analysis was performed to assess for factors independently associated with a total length of hospital stay of 5 days or less. Fifty-five percent were male (mean age, 62 years), 57.5% had an ASA III or IV, 76.9% had cancer, and 28.6% had low rectal procedures; 46.3% were completed laparoscopically. The median length of stay was 6.5 days with a mean of 8.6 days. On bivariate analysis, strategies associated with a stay ≤5 days were preoperative counseling, avoidance of oral bowel preparation, use of a laparoscopic approach, use of a transverse incision, introduction of clear fluids on day of surgery, and early discontinuation of the Foley catheter (all P

Aims Venous invasion (VI) is a known independent prognostic indicator of recurrence and survival in colorectal cancer. The guidelines of the Royal College of Pathologists (RCPath) state that, in a series of resections, extramural VI should be detected in at least 25% of specimens. However, there is widespread variability in the reported incidence, and this may affect patient access to adjuvant therapy. This study aims to clarify the current practice patterns of pathologists regarding the assessment of VI and to identify factors associated with an increased self-reported VI detection rate. Methods A population-based survey was mailed to 361 pathologists in the province of Ontario, Canada. Results The overall response rate was 64.9%. Most pathologists were practicing in community-based centres (66.2%) and approximately half had been in practice for over 15 years (53.5%). A subspecialist interest in gastrointestinal (GI) pathology was declared by 27.3% of pathologists. The majority of pathologists (70.2%) reported that they detected VI in less than 10% of resection specimens, with only 9.1% reporting VI detection rates above 20%. Standardised reporting criteria were applied by 62.1%. Special stains were employed by 57.6% if VI was suspected on H&E-stained sections. Practice in a university-affiliated centre, a subspecialist interest in GI pathology and the acceptance of the ‘orphan arteriole’ sign were all independently associated with a self-reported VI detection rate above 10% on multivariate analysis. Conclusions Self-reported VI detection rates are low among most pathologists. Even among specialist GI pathologists practicing in university-affiliated centres, few reported a detection rate close to that recommended by the RCPath. Strategies to increase the detection of VI may be required.

Background Little is known about the postoperative status and support needs of patients undergoing colorectal cancer operations. The objective of this study was to describe the disposition and resource use of Ontario’s elderly population undergoing colorectal cancer operations as well as to identify predictors of outcomes using population-based data. Methods A total of 33,238 patients aged 50 years and older with a diagnosis of colorectal cancer were identified using International Classification of Diseases 9 and 10 codes in the Ontario Cancer Registry linked to procedure codes in the Canadian Institute for Health Information Discharge Abstract Database representing colorectal operations within 6 months of diagnosis from 1997 to 2004. Data on an individual’s home-care use were collected from the Ontario Home Care Administrative System. The cohort was divided into the following age groups: 50–64 years, 65–74 years, 75–79 years, and 80 years and older. The primary outcomes assessed were postoperative mortality, length of stay, discharge disposition, need for home care, and readmission within 30 days. Results Based on univariate and multivariate analyses, patients aged 75–79 years and 80 years and older were more likely to die in hospital (odds ratio 2.84; 95% confidence interval 2.32–3.47 and odds ratio 5.72; 95% confidence interval 4.76–6.88), stay longer in hospital (2.78 [standard error 0.22] and 5.16 [standard error 0.19] days, respectively), not return home (odds ratio 5.62; confidence interval 3.99–7.98 and odds ratio 11.59; confidence interval 8.32–16.13), receive home care (odds ratio 1.44; 95% confidence interval 1.34–1.55 and odds ratio 1.71; 95% confidence interval 1.59–1.83), and be readmitted (odds ratio 1.31; 95% confidence interval 1.19–1.45 and odds ratio 1.59; 95% confidence interval 1.44–1.75) compared with younger individuals. The rate of discharge home for patients aged 80 years and older was more than 78%. Factors predisposing patients older than 75 years to poorer outcomes were higher Charlson comorbidity score, urgent admission, construction of a stoma, and reoperation. Conclusion Although discharge-related outcomes worsen with age, most elderly patients do well and can return home after a colorectal cancer operation. Elderly patients require more support; therefore, discharge planning should be part of preoperative assessment and discussions.

BACKGROUND: The objective of this study was to elicit future patients' preferences for preoperative chemoradiation (pre-CRT) for rectal cancer to determine whether patients' preferences are consistent with current treatment guidelines. METHODS: During a standardized interview, the treatment protocol, risks, benefits, and long-term outcomes associated with 1) surgery alone (SA) and 2) pre-CRT followed by surgery (CR + S) were described to healthy individuals, and a threshold task was performed. Each participant was asked which treatment option they would prefer when the risk of local recurrence was set initially at 15% for both options. If the participant indicated SA (which was expected), then the risk of local recurrence for CR + S was lowered systematically until the participant's preference changed from SA to CR + S. This threshold point represented the risk of local recurrence for pre-CRT that the participant would require before they would choose treatment with pre-CRT. RESULTS: Fifty individuals participated in the study, and the majority were well educated. Twenty-seven of 50 participants (54%) required a risk of local recurrence with CR + S of ≤5% (ie, equivalent to an absolute risk reduction ≥10%) before they would choose treatment with pre-CRT. Regression analysis did not identify any variables that were predictive of the participants' preferences. CONCLUSIONS: Participants seemed to highly value functional outcomes and seemed willing to accept a higher risk of local recurrence to achieve this. Therefore, developers of future guidelines may need to downgrade the use of pre-CRT for all patients with stage II/III tumors from a guideline to an option. Cancer 2011. © 2011 American Cancer Society.

The aim was to determine the frequency with which thromboprophylaxis is prescribed, factors predicting its prescription, and the frequency of symptomatic venous thromboembolism in patients admitted with acute abdominal conditions. Charts of patients admitted with acute abdominal conditions that did not have surgery for at least 24 h following admission were audited to identify if thromboprophylaxis was prescribed, if it was prescribed appropriately, factors affecting its prescription, and the rate of symptomatic venous thromboembolism. Of 350 patients (176 females, mean age 64.9 ± 18.6), 194 (55.4%) were admitted for bowel obstruction, 113 (32.3%) for biliary conditions, 14 (4.0%) for diverticulitis, 8 (2.3%) for pancreatitis, and 21 (6.0%) for other conditions. One hundred forty-two (40.6%) underwent surgery. Two hundred fifty-two (72.0%, 95% CI 67.3–76.7%) received thromboprophylaxis although only 199 (56.9%, 95% CI 51.7–62.1%) received adequate thromboprophylaxis. Hospital site and having surgery were associated with prescription of thromboprophylaxis. Twelve patients (3.4%, 95% CI 1.5–4.3%) developed symptomatic venous thromboembolism (nine deep venous thrombosis, three pulmonary embolism). Despite patients admitted with acute abdominal conditions being at high risk for development of symptomatic venous thromboembolism, many do not receive adequate thromboprophylaxis. Further work is required to decrease this gap in care.

Purpose Patient decision aids are interventions designed to help patients make deliberative choices about their treatment options and have been shown to significantly improve patient outcomes. Although considered optimal, decision aids are not widely used in clinical practice for cancer treatment. The objectives of this study are to determine physicians' awareness and use of decision aids, physicians' perceptions of the major barriers to the use of decision aids, and physician characteristics predictive of use of decision aids in clinical practice. Methods A population-based survey was mailed to general surgeons, medical oncologists, and radiation oncologists. Results The survey was mailed to 878 physicians, and the overall response rate to the survey was 64.5%. The majority of the participants were male and working in community hospitals for more than 10 years. Overall, 69% of the respondents were aware of decision aids, and 46% were aware of decision aids relevant to their practice. However, only 24% were currently using decision aids. The main barriers to the use of decision aids were reported as lack of awareness, lack of resources, and lack of time. Multivariate analysis showed specialty to be the only physician characteristic influencing the use of decision aids. Conclusion Approximately one third of physicians treating cancer patients are not aware of what decision aids are, and only 24% are currently using decision aids in clinical practice. Strategies to increase physician awareness about decision aids and to implement these tools into clinical practice are important.

Background and Objectives There is evidence of gaps in care for colorectal cancer surgery related to obtaining negative resection margins and lymph node assessment. Recommendations on the surgical and pathological management of curable colon and rectal cancer were developed. Methods A systematic review on colorectal resection margins and lymph nodes was conducted. This evidence, combined with evidence from existing guidelines and expert consensus, was used to develop recommendations. The draft guideline was reviewed by an expert panel and was externally reviewed by practitioners in Ontario, Canada. Results The search of the recent literature identified 107 articles pertinent to resection margins and lymph node assessment. The majority of the evidence was of poor quality. Of the 63 practitioners who reviewed the guideline, 97% agreed with the draft recommendations and 92% thought that the report should be approved as a practice guideline. Conclusions Achieving optimized performance concerning margin status and lymph node assessment requires the coordinated efforts of surgeons and pathologists, as well as other medical professionals. Focus should be on ensuring that colorectal cancers are resected with negative (R0) margins and that an adequate number of lymph nodes are assessed to allow for accurate decision making relating to prognosis and adjuvant therapy. J. Surg. Oncol. 2010;101:5–12. © 2009 Wiley-Liss, Inc.

BackgroundLaparoscopic ventral and incisional hernia repair has been reported in a number of small trials to have equivalent or superior outcomes to open repair.MethodsRandomized controlled trials comparing laparoscopic and open incisional or ventral hernia repair with mesh that included data on effectiveness and safety were included in a meta-analysis.ResultsEight studies met the inclusion criteria. There was no difference between groups in hernia recurrence rates (relative risk 1·02 (95 per cent confidence interval (c.i.) 0·41 to 2·54)). Duration of surgery varied. Mean length of hospital stay was shorter after laparoscopic repair in six of the included studies; the longest mean stay was 5·7 days for laparoscopic and 10 days for open surgery. Laparoscopic hernia repair was associated with fewer wound infections (relative risk 0·22 (95 per cent c.i. 0·09 to 0·54)), and a trend toward fewer haemorrhagic complications and infections requiring mesh removal.ConclusionLaparoscopic repair of ventral and incisional hernia is at least as effective, if not superior to, the open approach in a number of outcomes.

PURPOSE: This study was designed to characterize the presentation, care, and outcomes of persons older than 75 years, compared with persons 50 to 74 years of age, selected for colorectal cancer. METHODS: Patients over the age of 50 years who had surgery for colon or rectal cancer at the Mount Sinai Hospital between 1997 and 2006 were identified. Data were obtained from a colorectal cancer database and from office and hospital records. Patients were assigned to two groups: 50 to 74 years old and 75 years and older. RESULTS: There were 623 patients in the younger group (mean age, 62.6 years) and 275 in the older group (mean age, 81.5 years). The in-hospital mortality rate was 1% in the younger group compared with 4.2% in the older (P = 0.002). The overall five-year survival was 68.7% and 57.3% in the younger and older groups, respectively, whereas colorectal cancer-specific five-year survival was not significantly different (74.0% vs. 74.7%). There were significant differences between the two groups with respect to cancer location, American Society of Anesthesiologists' score, stage, proportion detected by screening, length of stay, and use of chemotherapy. CONCLUSIONS: Long-term colorectal cancer-related outcomes in the older group are similar to the outcomes in younger patients, suggesting that the decision to operate should not be based on age alone.

Background This study evaluated surgical site infection (SSI) prevention strategies at a network of university hospitals to identify interventions that may be required to improve compliance with guidelines. Methods Qualitative methods were used for thematic analysis of institutional tools and protocols, and transcripts of interviews with 7 surgical division heads and 11 professional managers of quality improvement or infection prevention and control at 7 hospitals. They were asked about awareness of, and accountability for, SSI prevention, and current and recommended strategies to promote compliance. Results Despite awareness of SSI prevention guidelines and the presence of organizational factors thought necessary for quality improvement (coordinators, champions), most sites had not reviewed their own practice and implemented corrective strategies. Barriers included use of passive educational strategies, lack of clinician accountability, limited implementation of point-of-care tools, and an absence of performance data. Conclusion The sites involved in this evaluation and others interested in increasing compliance with SSI prevention guidelines might implement education and performance data in tandem with accountabilities that trigger action, more actively engage champions to promote SSI prevention, create or update and incentivize use of tools such as standard orders, and encourage greater teamwork through organizational support of quality improvement.