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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) [...]

The comparative performance of synthetic and biologic meshes in complex and contaminated abdominal wall repairs remains controversial. Though biologic meshes are generally favoured in contaminated fields, this practice is based on limited data. Standard dictum regarding infected mesh is to either explant it early or pursue aggressive conservation measures depending on mesh position and composition. Explantation is typically morbid, leaving the patient with recurrent hernias and few reconstructive options. We report a case in which a hernia repaired with synthetic mesh recurred and was reconstructed with underlay biologic mesh. Delayed wound hematoma occurred after initiating anticoagulation for late postoperative pulmonary embolism, which became chronically infected. After multiple failed attempts at medical and interventional salvage of the mesh infection, the patient underwent selective explantation of synthetic mesh with conservation of the underlying biological mesh. She recovered completely without recurrent abdominal wall failure at long-term follow-up. We suggest the 'salvageable' characteristics of biologic meshes may allow conservation, rather than explantation, in select cases of infection., The use of synthetic and/or biologic meshes have become standard of care in most abdominal surgeries involving ventral abdominal wall reconstruction. Surgeons have largely abandoned suture repair in favour of [...]

Background: Complex abdominal wall reconstruction technique remains controversial. The use of biologic mesh products is also debated in active infection, sepsis prophylaxis and high-risk patients. Differences in biologic mesh technology and cost remain significant. We aimed to compare the efficacy of 2 commonly used biologic meshes in regards to hernia recurrence at 1 year. Methods: This study was a parallel, dual-arm, double-blind randomized controlled trial involving adult patients undergoing complex abdominal wall reconstruction with a biologic mesh at a quaternary care institution (2017-2020). Patients were randomly assigned to receive Permacol (cross-linked) compared with Strattice (not crosslinked). The main outcome measure was hernia recurrence at 1 or more years following the index repair. Results: We included 94 patients randomized to undergo reconstruction with 1 of 2 commonly used biologic mesh products (mean age 59.4 yr, standard deviation [SD] 9.9; 51% female; body mass index 32.9, SD 6.8). We found no significant differences between the groups (patient comorbidities, hernia recurrence risk factors, hernia size or infection profiles). Hernia recurrence rates (15%) were similar between groups (median 783 days of follow up, interquartile range 119). We found there was significantly less of a need for a component separation technique in the Strattice group (69% v. 87%). All other secondary outcome measures were equivalent between study arms. Multivariate analysis identified hepatic transplantation (odds ratio [OR] 1.94, 95% confidence intervals [CI] 0.33-4.41), active abdominal wall infection (OR 2.01, 95% CI 0.50-7.01), and more than 1 previous hernia repair (OR 2.68, 95% CI 0.41-5.99) as risk factors for subsequent hernia recurrence; however, there was no difference in recurrence factors between patient study groups. Conclusion: Given similar clinical performance between the 2 most commonly used biologic mesh products, the most cost effective mesh should be used in cost-conscious health care systems. Contexte : Les techniques de reconstruction complexe de la paroi abdominale demeurent un sujet controverse. L'utilisation de treillis biologique ne fait pas non plus consensus dans les cas d'infection active et de prophylaxie du sepsis, ni chez les patients a risque eleve. Les differences dans la technologie employee et le cout des divers produits sur le marche demeurent considerables. Nous avons cherche a comparer l'efficacite de 2 treillis biologiques couramment utilises a prevenir la recidive de hernie apres 1 an. Methodes : Le modele d'etude choisi etait un essai clinique randomise a double insu en 2 bras paralleles auquel ont participe des patients qui subissaient une reconstruction complexe de la paroi abdominale a l'aide d'un treillis biologique dans un etablissement de soins quaternaires (de 2017 a 2020). Apres repartition aleatoire, les patients ont recu le treillis Permacol (reticule) ou le treillis Strattice (non reticule). L'indicateur de resultat principal etait la recurrence de hernie 1 an ou plus apres la reconstruction initiale. Resultats : Nous avons inclus 94 patients qui, apres repartition aleatoire, ont subi une reconstruction avec 1 des 2 treillis biologiques couramment utilises ici a l'etude (age moyen 59,4 ans, ecart-type [E.-T.] 9,9, proportion de femmes 51 %, indice de masse corporelle 32,9, E.-T 6,8). Nous n'avons observe aucune difference significative entre les groupes (comorbidite, facteurs de risque de recidive de la hernie, taille de la hernie ou profil infectieux). Les taux de recidive des hernies (15 %) etaient similaires dans les 2 groupes (mediane 783 j post-intervention; ecart interquartile 119). Nous avons observe un besoin moins frequent de la technique de separation des composants dans le groupe (69 % c. 87 %). Tous les autres indicateurs de resultats secondaires etaient comparables dans les 2 bras de l'etude. Selon l'analyse multivariee, la transplantation hepatique (rapport des cotes [RC] 1,94, intervalle de confiance [IC] de 95 % 0,33-4,41), l'infection active de la paroi abdominale (RC 2,01, IC de 95 % 0,50-7,01) et des antecedents de plus d'une chirurgie de la hernie (RC 2,68, IC de 95 % 0,41-5,99) seraient des facteurs de risque de recidive subsequente de la hernie; cependant, aucune difference dans les facteurs de recurrence n'a ete constatee entre les 2 groupes. Conclusion : Compte tenu des resultats cliniques similaires obtenus avec les 2 treillis biologiques les plus couramment utilises, les systemes de sante pour lesquels la rationalisation des couts est importante devraient choisir le produit le plus economique., Incisional hernias after abdominal operations are unfortunately common for patients (up to 23%) and costly to health care systems. (1-6) In patients who pursue surgical repair by way of abdominal [...]

Surgical programs are facing major and fluctuating changes to the resident workforce because of decreased elective volumes and high exposure risk during the coronavirus disease 2019 pandemic. Rapid restructuring of a residency program to protect its workforce while maintaining educational value is imperative. We describe the experience of the Division of General Surgery at the University of Ottawa in Ontario, Canada. The residency program was restructured to feature alternating 'on' and 'off' weeks, maintaining a healthy resident cohort in case of exposure. Teams were restructured and subdivided to maximize physical distancing and minimize resident exposure to pathogens. Educational initiatives doubled, with virtual sessions targeting every resident year and incorporating intraoperative teaching. The divisional research day and oral exams proceeded uninterrupted, virtually. A small leadership team enabled fast and flexible restructuring of a system for patient care while prioritizing resident safety and maintaining a commitment to resident education in a pandemic., The coronavirus disease 2019 (COVID-19) pandemic presents an unprecedented challenge to health care. As of April 19, 2020, Ontario had approximately 10 500 confirmed cases (1) and adopted physical distancing [...]