BACKGROUND:Studies show that near-peer, simulation-based training can help develop technical skills. We sought to examine the effectiveness of near-peer instruction in otolaryngology emergencies by assessing student knowledge and procedural confidence before and after a 2-hour workshop. METHODS:We designed a pilot study for an otolaryngology workshop led by a second-year resident and 2 third-year medical students. The workshop consisted of lectures for anatomy and procedural overview, followed by hands-on simulation stations. Participants completed pre- and post-workshop quizzes and surveys to assess confidence in epistaxis management, cricothyrotomy, and nasolaryngoscopy. RESULTS:Sixteen medical students participated (mean age 25.8 yr). Median quiz scores increased significantly from 7 to 17 out of 21 after the workshop (p = 0.0005; median change 10, 95% confidence interval 6.0 to 11.5). Median self-reported confidence in epistaxis management, cricothyrotomy, and nasolaryngoscopy significantly improved from 2 to 3 (p = 0.003), 1 to 3 (p = 0.0009), and 1 to 3 (p = 0.001) out of 4, respectively. Among participants, the likelihood of attending this workshop again or recommending it to peers was high (median score 4/4). CONCLUSION:The workshop effectively improved knowledge and procedural confidence in epistaxis management, cricothyrotomy, and nasolaryngoscopy among medical students. It was well received, with high satisfaction scores, and feasible to coordinate.
SummaryAnesthesia workforce shortages are an increasingly important contributor to operating room closures and surgical delays. These gaps disproportionately affect rural and regional hospitals, limiting equitable access to surgery. This commentary outlines how Canada can modernize the anesthesia care team (ACT) model to sustain surgical capacity while maintaining patient safety. Anesthesia assistants (AAs), trained professionals working under anesthesiologist supervision, already support perioperative care in many centres but remain underutilized. Standardizing AA credentials, defining supervision based on case conditions rather than fixed ratios, and implementing transparent safety reporting could expand access responsibly. Surgeons, as procedural leaders whose productivity depends on anesthesia workforce availability, should understand the ACT framework and its safeguards. Strengthening collaboration between surgical and anesthesia leadership offers a practical path to preserve access to surgery and reduce wait times without compromising safety.
SummaryReprocessing single-use arthroscopic instruments - particularly radio-frequency devices and suture-passing devices - has become standard practice in Zhejiang Province, China. Although this approach offers substantial economic advantages, emerging evidence suggests that reuse of certain items may pose elevated risks of thermal injury and mechanical failure. Here, we discuss the prevalence of this practice within China, outline documented hazards, propose evidence-based mitigation strategies, and explore the ethical dimensions of resource-limited surgical care.
BACKGROUND:Patients presenting to hospital with emergency general surgery (EGS) conditions such as appendicitis, biliary disease, and hernias represent 11% of hospital admissions in Canada. This study evaluated the establishment of a local registry of EGS patients by auditing the accuracy of data abstracted from administrative records compared with manual chart review. METHODS:Patients admitted to and consulted by the Acute Care Surgery (ACS) service at London Health Sciences Centre during a 1-year period were entered into a prospective registry. Data on demographics, comorbidities, imaging, diagnosis, treatment, and outcomes were collected from both manual chart review of patient electronic health records and routinely collected administrative data. Accuracy of data from administrative sources compared with those from manual chart review was audited for a 6-month period. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for comorbidities, imaging, and complications to determine which variables can be accurately collected using administrative data. RESULTS:A total of 2159 patients were included in the analysis. Overall accuracy was good for most comorbidities, ranging from 83.8% to 100%; however, sensitivity, specificity, NPV, and PPV ranged drastically, suggesting that data on some comorbidities may not be accurately collected through health records. Imaging procedures were consistent between the 2 data collection methods, with good overall accuracy of 97.6%. For assessed complications, accuracy was excellent overall, with an average accuracy of 99.6% (range 98.3% to 100%). CONCLUSION:This study shows that a substantial portion of data necessary for an ACS registry can be reliably extracted from routinely collected administrative data.
SummaryProfessional recommendations are subjective and inherently biased. When singing a candidate's praises, references can lead to successful appointments; however, their content can also negatively influence outcomes and, in extreme cases, damage a candidate's reputation and career. This commentary discusses the need for a more modern, standardized approach to professional references to address favouritism and discrimination in the process of appointing staff surgeons.
SummaryNormothermic regional perfusion (NRP) is a strategy to improve organ quality in donation after circulatory death by restoring near-physiologic perfusion after circulatory arrest. Although its benefits are established in liver and kidney transplantation, its application to pancreas recovery and clinical islet transplantation is limited. Given the pancreas sensitivity to warm ischemia and the limited functional reserve inherent to islet transplantation, NRP may offer advantages over conventional cold recovery. We report our initial experience utilizing NRP for pancreas recovery in islet transplantation. Islet isolation yielded a high islet mass with excellent viability despite low donor body mass index, a factor traditionally associated with poor yield. Transplantation resulted in rapid improvement in glycemic control, reduced insulin requirements, resolution of hypoglycemia and favourable early graft function. This experience supports further evaluation of NRP to expand pancreas grafts utilization from donation after circulatory arrest and improve islet transplant outcomes.
BACKGROUND:Peripheral nerve injuries can be devastating - often resulting in chronic pain, disability, and diminished quality of life - but prompt referral to a peripheral nerve surgeon can facilitate diagnostic assessment, optimize surgical timing and options, and enhance functional recovery. We sought to examine the timing and referral patterns of patients with peripheral nerve injuries attending a multidisciplinary peripheral nerve clinic at a tertiary care centre. METHODS:We conducted a retrospective, single-centre cohort study. We performed a chart review of all patients seen at a multidisciplinary peripheral nerve clinic at a tertiary care centre in Canada between 2017 and 2020. Data collected included demographics, injury details, referral information, and management. RESULTS:We included 100 patients for analysis. The median time from injury to referral was 112 (interquartile range [IQR] 40 to 367) days. Sixty percent of patients had a delayed referral (> 3 mo). After adjusting for potential confounding variables (injury level, mechanism of injury, and referral source), we found a 4% increased risk of experiencing a longer time from injury to referral for each unit increase in a patient's Rurality Index for Ontario score (adjusted rate ratio 1.04, 95% confidence interval 1.00 to 1.08). The median time from injury to operation was 244 (IQR 355) days, predominantly involving nerve procedures (n = 31/38, 82%). CONCLUSION:The study illustrates the referral patterns and timeline of care for patients with peripheral nerve injuries at a multidisciplinary nerve clinic in Canada. Patients from areas of higher rurality indices have a higher risk of experiencing increased time from injury to referral. CONTEXTE:Les lésions nerveuses périphériques peuvent être dévastatrices, entraînant souvent douleur chronique, incapacité et baisse de la qualité de vie. Toutefois, l'orientation rapide vers un ou une spécialiste de la chirurgie des nerfs périphériques peut faciliter l'évaluation diagnostique, optimiser le moment de l'intervention chirurgicale ainsi que les options thérapeutiques, et améliorer le rétablissement fonctionnel. Nous avons voulu examiner le délai et les modalités de l'aiguillage de personnes atteintes de lésions nerveuses périphériques ayant été orientées vers la clinique multidisciplinaire des nerfs périphériques d'un centre de soins tertiaires. MÉTHODES : Nous avons mené une étude de cohorte rétrospective monocentrique. Nous avons passé en revue les dossiers de l'ensemble des personnes vues à la clinique multidisciplinaire des nerfs périphériques d'un centre de soins tertiaires canadien entre 2017 et 2020. Les données recueillies comprenaient les caractéristiques démographiques, les détails concernant la lésion ainsi que les renseignements relatifs à l'aiguillage et à la prise en charge. RÉSULTATS : Nous avons inclus 100 personnes dans l'analyse. Le délai médian entre la lésion et l'orientation était de 112 (intervalle interquartile [IIQ] de 40 à 367) jours. Chez 60 % des personnes, l'aiguillage avait été tardif (plus de 3 mois). Après correction pour tenir compte des potentielles variables confondantes (siège et mécanisme de la lésion, et origine de l'aiguillage), nous avons constaté une augmentation de 4 % du risque d'un délai plus long entre la lésion et l'aiguillage pour chaque augmentation d'une unité de l'indice de ruralité de l'Ontario (rapport des taux corrigé de 1,04, intervalle de confiance à 95 % de 1,00 à 1,08). Le délai médian entre la lésion et l'intervention chirurgicale était de 244 jours (IIQ de 355), et les interventions concernaient principalement les nerfs (n = 31/38, 82 %). CONCLUSION:Cette étude illustre les caractéristiques de l'aiguillage et la chronologie de la prise en charge des personnes atteintes de lésions nerveuses périphériques suivies dans une clinique multidisciplinaire des nerfs périphériques au Canada. Les personnes provenant de régions à l'indice de ruralité plus élevé courent un risque accru de délai plus long entre la lésion et l'aiguillage.
BACKGROUND:Curative-intent surgical treatment for hepatocellular carcinoma (HCC) varies in complexity and resource requirements, potentially leading to regional disparities in access. We sought to assess the incidence of HCC and geographic variation in access to treatment (liver transplantation or resection) and outcomes across Ontario. METHODS:We conducted a retrospective, population-based cohort study using ICES administrative data of patients who received a first HCC diagnosis in Ontario between 2004 and 2021. We stratified patients by Local Health Integration Network (LHIN) to evaluate regional differences in treatment and outcomes. Descriptive statistics summarized demographics, treatment patterns, and survival outcomes. RESULTS:We included 18 494 patients with a mean age of 63.4 (standard deviation 5.3) years, of whom 37.2% were female and 10.6% lived in rural areas. The age- and sex-standardized incidence rate of HCC was 16.8 per 100 000 people, with metabolic-associated steatotic liver disease as the leading cause (55.1%). Treatment varied by region, with most surgeries performed in urban areas. Survival differed significantly, with the top 3 LHINs located in central Ontario and the poorest outcomes in remote regions. CONCLUSION:Geographic differences in surgical treatment and survival observed across Ontario are likely multifactorial and may reflect differences in clinical presentation, patient demographics, and system-level factors influencing care pathways. These differences highlight opportunities to strengthen HCC care delivery and coordination across the province. CONTEXTE:Les traitements chirurgicaux à visée curative contre le carcinome hépatocellulaire (CHC) se présentent avec des degrés de complexité et des besoins en ressources divers, menant potentiellement à des disparités régionales en matière d'accès. Nous cherchons à évaluer l'incidence du CHC et les variations géographiques de l'accès aux traitements (transplantation ou résection hépatique) et leurs résultats en Ontario. MÉTHODES : Nous avons réalisé une étude de cohorte rétrospective de population fondée sur des données administratives de l'Institut de recherche en services de santé (IRSS) provenant de patients ayant obtenu un premier diagnostic de CHC entre 2004 et 2021, en Ontario. Nous avons regroupé les patients selon leur Réseau local d'intégration des services de santé (RLISS) afin d'évaluer les différences régionales au niveau des traitements et des résultats. Les statistiques descriptives récapitulent les données démographiques, les modalités thérapeutiques et les chances de survie. RÉSULTATS : Nous avons inclus 18 494 malades ayant un âge moyen de 63,4 (écarttype de 5,3) ans, dont 37,2 % étaient de sexe féminin et 10,6 % résidaient en milieu rural. Les taux d'incidence normalisés selon l'âge et le sexe du CHC étaient de 16,8 par 100 000 habitants, avec comme cause principale la stéatose hépatique associée à un dysfonctionnement métabolique (55,1 %). Les avenues thérapeutiques variaient selon les régions, avec la grande majorité des interventions chirurgicales réalisées en zones urbaines. Les taux de survie variaient grandement, les 3 meilleurs RLISS se situant dans le centre de l'Ontario et ceux présentant les moins bons résultats étant situés en régions éloignées. CONCLUSION:Les différences géographiques en matière de traitements chirurgicaux et de taux de survie observées à travers l'Ontario sont probablement multifactorielles et peuvent être le reflet de différences dans le tableau clinique et les caractéristiques démographiques des patients ainsi que d'autres facteurs systémiques influençant les trajectoires de soins. Ces différences mettent en lumière des occasions de renforcer la prestation des soins contre le CHC, de même que la coordination à l'échelle de la province.
Background: People experiencing homelessness suffer from a high burden of surgical conditions and face many barriers to accessing care. Our aim was to describe the unmeasured and unmet need of surgical care through outpatient surgical referrals. Methods: This is a retrospective review of electronic patient charts from the Shelter Health Network, a health care and social service organization serving people experiencing homelessness in Hamilton, Ontario, Canada. The review spanned a 2-year period from 2017 to 2018 and included referrals to all outpatient surgical services (except ophthalmology) and endoscopy. Results: In total, 167 surgical referrals were sent for 129 patients over the 2-year period. The average age of patients was 46 years, and 95% had provincial health insurance. Among referrals, 93% resulted in a scheduled appointment, and 58% resulted in the patient seeing a surgical provider. Overall, 61 surgical procedures were proposed and 64% of these were completed. Major procedures were completed at a higher rate than minor procedures. Patient, provider, and system factors contributed to patients not receiving care. Conclusion: To our knowledge, this is the first study to describe outpatient surgical referrals by primary care providers for people experiencing homelessness. There were significant gaps in both the accessing of surgical consultation and in the completion of proposed surgical procedures. These represent an ongoing unmet need for surgical care. We divided barriers into systemic, provider, and patient barriers, and those that have direct applications to policy and practice.
Cystic echinococcosis (CE) is rare in Canada but continues to appear sporadically, sometimes in patients who have not travelled to endemic regions. Since 2010, World Health Organization (WHO) guidelines have emphasized stage-specific management, yet the extent to which this approach is applied in Canadian practice is uncertain. We reviewed 41 cases of CE managed in British Columbia between 2010 and 2022; only about two-thirds received treatment aligned with WHO guidance. The primary gap was in radiology reporting, which frequently documented cyst size but omitted the staging details essential for surgical decision-making. Although outcomes were generally favourable, the lack of standardized pathways led to unnecessary clinical variation. Structured radiology reporting, multidisciplinary oversight and provincial collaboration remain essential to ensure consistent, evidence-based care, especially for rare diseases where experience is limited.
BACKGROUND:Demand for reconstructive surgery postmastectomy has risen, prompting evaluation of its economic impact in a publicly funded health care system. We sought to explore factors associated with increased costs of hospital admission following autologous breast reconstruction. METHODS:We conducted a retrospective cohort study involving patients who underwent autologous breast reconstruction in Ontario, Canada (2005 to 2020). Patients received either a pedicled transverse rectus abdominis myocutaneous (TRAM) flap or free tissue transfer. We analyzed costs from the hospital perspective, from admission to discharge. We used generalized linear models with a γ distribution to identify cost-associated factors. RESULTS:Of 2634 patients, 378 (14.4%) underwent pedicled TRAM and 2256 (85.7%) underwent free flap reconstruction. The median cost of hospital admission was $8816 (interquartile range $3383 to $90 974). Univariate analysis identified cost drivers including length of stay, reconstruction type, age, income quintile, laterality, and emergency reoperation. Multivariable analysis showed increased costs associated with free flap reconstruction (13% increase, 95% confidence interval [CI] 5% to 22%; p < 0.001), age older than 70 years (31% increase, 95% CI 7% to 61%; p < 0.01), lower income quintile (10% increase, 95% CI 3% to 18%; p = 0.01), and bilateral reconstruction (11% increase, 95% CI 1% to 23%; p = 0.03). Hospital type, geographic region, timing of reconstruction, comorbidities, and rurality were not significantly associated with cost. CONCLUSION:Free flap reconstruction, bilateral procedures, and advanced age are key drivers of hospital admission costs. These findings may inform policy and resource-allocation strategies in publicly funded systems to optimize value in breast reconstruction care.
Background: The direct anterior approach for total hip arthroplasty (DAA THA) is believed to be a tissue-sparing approach that aims to spare the short external rotator (SER) tendons and posterior capsule, but the rate of SER release is unknown. We sought to prospectively determine the early appreciable percentage of SER tendon release among patients undergoing DAA THA for osteoarthritis using magnetic resonance imaging (MRI). Methods: We recruited participants undergoing DAA THA for osteoarthritis for this single-centre, prospective study. All participants underwent a 1.5 T MRI preoperatively and 3 months postoperatively. The surgeon recorded the status of SER tendons intraoperatively. Two fellowship-trained musculoskeletal radiologists independently reviewed MRIs for integrity of SER tendons at each time point. Results: We recruited 25 participants with Kellgren-Lawrence grade 3 or 4 osteoarthritis. The average age was 65 (range 51 to 80) years, and the average body mass index was 28.2 (range 21.2 to 40.8). Of the 25 participants, 13 (52%) were male; 14 (56%) participants were undergoing THA for their left hip. On preoperative MRI, all SER tendons were intact. Intraoperatively, the surgeon reported 2 (8%) purposeful releases of the obturator internus for assistance on exposure and no purposeful piriformis or obturator externus releases. On postoperative MRI, consensus reading concluded complete release of the obturator internus in all participants (100%), piriformis release in 72% of participants, and obturator externus release in 4% of participants. We observed significant differences between SER tendon integrity on postoperative MRI and the surgeon's reported releases for obturator internus and piriformis (p < 0.001). Conclusion: Given the complexity of attachment of conjoint and piriformis tendons to the lateral capsule and appropriate stem positioning, release of these tendons viewed on MRI is inevitable. This may be owing to their inadvertent release during capsular exposure, as these tendons merge with the capsule, or during lateralization and posterization rasping of the femoral broach, especially for the obturator internus.
Drug overdose has killed tens of thousands of people in Canada. Surgery and postoperative opioid prescriptions introduce narcotics to opioid-naive patients, with risk as high as 13% for prolonged opioid use long after surgical recovery. Surgeons in North America prescribe opioids to more patients, and in much higher doses, to manage postoperative pain than surgeons in other countries for similar procedures. Yet, most postoperatively prescribed opioids often go unused by patients in North America. With 90% of opioids not taken as prescribed, this excess supply stocks the community for nonmedical opioid use. With opioid overdoses posing a public health crisis, we call on surgeons to be leaders in responsible opioid prescribing to reduce adverse effects of opioid use while maintaining adequate postoperative pain control.
Background: Use of sterile water in endoscopy is common practice but is not based on available evidence, as the literature suggests that the use of tap water in endoscopy is safe and appropriate, even for advanced procedures. We sought to examine the financial and environmental cost savings at our institution after switching from sterile to tap water for endoscopy. Methods: We conducted a comparative analysis of a period of use of sterile water irrigation (October 2022) in endoscopy to an equivalent period of use of tap water irrigation (October 2023). Advanced and invasive procedures continued to use sterile water during both study periods. Our analysis focused on the financial and environmental impact of switching to tap water. Results: The number of procedures remained stable, with 922 procedures during the sterile water phase and 905 procedures during the tap water phase. Introduction of tap water led to a substantial reduction in sterile water usage, from 336 to 192 bottles per month, saving $310.70 per month. The cost of irrigation water per procedure decreased from $0.80 to $0.47, representing a 41.2% cost reduction. Transitioning to tap water eliminated the need for 144 bottles per month, resulting in a monthly waste reduction of 17.45 kg. The estimated carbon footprint was 54.18 kg of carbon dioxide equivalents from production alone, excluding sterilization, transportation, and waste management. Conclusion: Use of tap water in endoscopy has been proven to be safe and effective. An additional benefit is the financial and environmental cost savings of decreasing sterile water use. Implementation of tap water protocols in endoscopy units can be a simple step toward increasing sustainability in endoscopy.
Background: Cancer care was negatively affected during the COVID-19 pandemic. We sought to examine the long-term effects of the COVID-19 pandemic on patterns of lung cancer care among patients undergoing surgical resection at our thoracic surgery program. Methods: We conducted a retrospective cohort study of all patients who underwent lung resection for cancer at Michael Garron Hospital between 2018 and 2024. We categorized patients into 3 cohorts: prepandemic (2018 to 2019), COVID-19 pandemic (2020 to 2022), and postpandemic (2023 to 2024). We analyzed demographic characteristics, time to surgery, length of stay, multimodal treatment, and pathological stage. Results: We included 1090 patients. The time from consent to surgery was shorter in the pandemic cohort (26 v. 29 d; p < 0.01). Length of stay was also shorter during the pandemic and postpandemic periods (median 2 v. 3 d; p < 0.001). A higher proportion of patients presented with advanced-stage lung cancer (stage III) in the prepandemic cohort than in the other cohorts (15% v. 9%, p < 0.05). Conclusion: We found no significant delays in surgical care for lung cancer during the COVID-19 pandemic. Timelines to surgery may have been expedited owing to increased resource allocation. Through further study of adaptive mechanisms used during the pandemic, we can continue to provide increasingly effective and efficient lung cancer care.
