Introduction Patients undergoing colorectal surgery with fecal ostomy experience biopsychosocial challenges during recovery. We aimed (1) to describe clinician's perceived challenges with biopsychosocial recovery after ostomy surgery and (2) to examine current solutions to address patient psychosocial challenges while recovering. Methods We conducted qualitative focus groups evaluating clinician perspectives using a semistructured interview guide. Colorectal surgeons, gastrointestinal psychologists, colorectal surgery nurse practitioners, and ostomy nurses were included. Results Five interview sessions were performed including focus groups and individual interviews. Clinicians were 73% female, all White, and with varied experience (2-40 y in practice). All participants reported ostomy-related emotional distress occurs after surgery and impacts patient recovery and adaptation. Participants reported distress was mitigated when the ostomy relieved functional symptoms and in patients with time to cope with needing an ostomy due to chronic diseases. Patients with permanent ostomies were felt to adapt faster. Emotional distress increased dependence on caregivers, prolonged hospital stays, and delayed adaptation to daily life. Ostomy nurses reported they spent significant time addressing patient distress in clinical encounters. Participants reported a lack of training, time, and resources to help manage patients’ emotional distress. Conclusions Clinicians treating colorectal surgery patients with ostomy frequently note clinically significant emotional distress. This distress hinders patients’ ability to adapt to life with an ostomy. An ostomy specific distress management intervention is needed to improve biopsychosocial outcomes during surgical recovery and adaptation.

BACKGROUND:With the advent of enhanced recovery after surgery pathways, older adults who undergo major elective surgery return home early in the postoperative period and rely more on care-partner support. Little has been done to assess current challenges that older patient/care-partner dyads experience after major elective surgery and to identify intervention targets to improve transitions home after surgery. METHODS:This multimethods study recruited 15 dyads of major elective surgery patients aged 65+ years from 3 surgical specialties and their care-partners (30 participants total). Demographic, quality of life, and caregiver burden surveys were completed. Each participant underwent a 1-on-1 interview exploring challenges, resources received, and communication experiences. Survey data were analyzed using descriptive statistics. Interview data were analyzed deductively, mapping themes onto the 5Ms of the Geriatrics framework. RESULTS:We enrolled 6 thoracic, 5 colorectal, and 4 orthopedic patients, along with their care-partners (n = 30). Most participants were female (67%) and educated (ie, college degree +, 57%). Zarit Burden Interview surveys suggested mild-moderate burden (9.3; standard deviation, 10.38) with thoracic care-partners reporting higher burden (14.33; standard deviation, 13.98). World Health Organization quality-of-life scores were also lower among thoracic surgery dyads. The range of when the interview occurred in relation to the surgery date was 1-5 months. Qualitative analysis revealed the need for emotional support, improved anticipatory guidance about expected recovery, and assistance with activities of daily living/independent activities of daily living and medication management. CONCLUSION:Older surgical patients and their care-partners identified specific targets to improve transitions out of the hospital during surgical recovery, including enhanced communication, education, and emotional/physical support. Surgical teams, researchers, and health care system leaders can use these findings to improve care quality and support care-partners assisting older adults.

BACKGROUND:This is the third updated enhanced recovery after surgery (ERAS®) society guideline presenting a consensus for optimal perioperative care in gynecologic oncology surgery. METHODS:A database search of publications using Embase and PubMed was performed (2018-2025). Studies for key elements within the ERAS gynecologic oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the grading of recommendations, assessment, development and evaluation (GRADE) system. RESULTS:All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS:The updated evidence base and recommendation for items within the ERAS gynecologic oncology perioperative care pathway are presented by the ERAS® society in this consensus review. Gynecologic surgeons may consider incorporating these recommendations into perioperative pathway design, with efforts to achieve consensus within their practice where feasible.

BACKGROUND:Education and support for ostomy are instrumental in surgical recovery and adaptation. This study aimed to evaluate (i) the challenges faced by fecal ostomy patients with colorectal cancer and (ii) the resources necessary for recovery. METHODS:This study recruited patients 21 to 90 days after scheduled fecal ostomy surgery for locally advanced or metastatic colorectal cancer from a single tertiary academic center. This study conducted 1:1 semistructured interviews until thematic saturation using hybrid deductive-inductive coding. RESULTS:This study interviewed 20 patients (80% male; mean age of 59.7 years). Several major themes emerged, including challenges in (i) practical ostomy management, (ii) emotional distress, (iii) adaptation to daily life, and (iv) provider relationships. The participants faced ostomy care challenges owing to peristomal skin issues, leaks, and difficulty ordering supplies. Many participants noted significant distress or anxiety related to embarrassment caused by leaks, odors, or noise. This distress led participants to fear going out in public, embarrassment from the ostomy, and anxiety about their daily activities (eg, returning to work and relationships). When adapting to life with an ostomy, several participants noted that anxiety affected their ability to care for the ostomy and resume their daily activities, leading to social isolation. Patients reported challenges with provider relationships and a lack of anticipatory guidance from the surgical team preoperatively, including insufficient education on practical management, ordering of ostomy supplies, ensuring adequate hydration, and maintaining proper nutrition. CONCLUSION:Patients with colorectal cancer who require fecal ostomy face several challenges related to ostomy. Interventions that address practical management, navigating distress, adaptation, and provider education are needed to provide tailored education and support.

AbstractEnhanced Recovery After Surgery (ERAS) is a global initiative comprised of a series of evidence-based interventions in the preoperative, intraoperative, and postoperative surgical phases. When implemented as a bundle, ERAS interventions both improve clinical outcomes and provide cost savings to the health care system. This review provides an update on the current evidence for individual ERAS elements to improve quality of care as well as practical recommendations for multidisciplinary teams to implement their own ERAS programs.

Enhanced Recovery After Surgery (ERAS) recommendations for multi-modal, opioid-limiting analgesia have been shown to be effective in paediatric patients. However, neonatal-specific protocols are limited, and protocols that address non-pharmacological approaches are rare. Through systematic review and modified Delphi consensus with anaesthesiologists, paediatric surgeons and researchers, we developed non-pharmacological recommendations to improve perioperative neonatal pain management. Evidence from 37 articles of variable quality informed these recommendations. Our consensus resulted in four recommendations: (1) use of sweet-tasting solutions, (2) non-nutritive sucking, (3) skin-to-skin and (4) music therapy. These recommendations aim to reduce neonatal opioid usage alongside pharmacological therapies. PROSPERO registration number: CRD42021265273.

Background Support for the treatment of uncomplicated appendicitis with non-operative management rather than surgery has been increasing in the literature. We aimed to investigate whether treatment of uncomplicated appendicitis with antibiotics in children is inferior to appendicectomy by comparing failure rates for the two treatments. Methods In this pragmatic, multicentre, parallel-group, unmasked, randomised, non-inferiority trial, children aged 5-16 years with suspected non-perforated appendicitis (based on clinical diagnosis with or without radiological diagnosis) were recruited from 11 children's hospitals in Canada, the USA, Finland, Sweden, and Singapore. Patients were randomly assigned (1:1) to the antibiotic or the appendicectomy group with an online stratified randomisation tool, with stratification by sex, institution, and duration of symptoms (>= 48 h vs <48 h). The primary outcome was treatment failure within 1 year of random assignment. In the antibiotic group, failure was defined as removal of the appendix, and in the appendicectomy group, failure was defined as a normal appendix based on pathology. In both groups, failure was also defined as additional procedures related to appendicitis requiring general anaesthesia. Interim analysis was done to determine whether inferiority was to be declared at the halfway point. We used a non-inferiority design with a margin of 20%. All outcomes were assessed in participants with 12-month follow-up data. The trial was registered at ClinicalTrials.gov (NCT02687464). Findings Between Jan 20, 2016, and Dec 3, 2021, 936 patients were enrolled and randomly assigned to appendicectomy (n=459) or antibiotics (n=477). At 12-month follow-up, primary outcome data were available for 846 (90%) patients. Treatment failure occurred in 153 (34%) of 452 patients in the antibiotic group, compared with 28 (7%) of 394 in the appendicectomy group (difference 267%, 90% CI 224-309). All but one patient meeting the definition for treatment failure with appendicectomy were those with negative appendicectomies. Of those who underwent appendicectomy in the antibiotic group, 13 (8%) had normal pathology. There were no deaths or serious adverse events in either group. The relative risk of having a mild-to-moderate adverse event in the antibiotic group compared with the appendicectomy group was 43 (95% CI 21-87; p<00001). Interpretation Based on cumulative failure rates and a 20% non-inferiority margin, antibiotic management of non-perforated appendicitis was inferior to appendicectomy.

Rationale & Objective: People with advanced kidney disease undergo more noncardiac operations compared with the general population, with a higher risk of perioperative cardiac events and death. However, little is known about the associations between severity of preoperative kidney dysfunction with postoperative length of hospitalization and discharge disposition; these were the focus of this study. Study Design: Population-based retrospective cohort. Setting & Participants: Adults from Alberta, Canada, undergoing inpatient major noncardiac surgery between April 2005 and February 2019. Exposure: Categorical preoperative outpatient estimated glomerular filtration rate (eGFR) or kidney failure status. Outcome: Length of stay (LOS), days alive at home after surgery within 30 and 90 days, and discharge disposition location. Analytical Approach: Associations were estimated with unadjusted and adjusted generalized estimating equation models. Results: We identified 927,560 inpatient surgeries in 666,770 people (55.9% female; median age, 57.4 years). People receiving dialysis had the longest LOS (11 days [95% CI, 6-29]), 2 times greater than that among people with normal kidney function (adjusted incidence rate ratio [IRR], 2.21 [95% CI, 2.102.32]). This group also had the fewest days alive at home within the first 30 days after surgery, with an IRR of 0.69 (95% CI, 0.670.70) compared with people with normal eGFR. The majority of people (82.8%) were discharged home without nursing support after surgery, though people receiving dialysis were discharged to a facility with 24-hour nursing care nearly 4 times more often. There were graded increases in risks of these outcomes with lower levels of kidney function. Limitations: Many people did not have preoperative kidney function assessed, reflecting standard clinical practice in the general population. Conclusions: After major surgery, people with kidney disease spend more time recovering in hospital and have less independence from postdischarge nursing supports than otherwise similar patients who have normal or near normal kidney function. These differences were more pronounced for those with the most severe stages of kidney disease.

Objective: This study describes differences in postoperative mortality for pediatric patients in rural communities compared to urban communities. Background: Canada has the second largest land mass in the world, with a population density of 4 people per km(2). There are 18 children's hospitals in Canada offering pediatric surgical services, all in urban centres, yet nearly one-fifth of the population lives in rural or remote communities. Children who live in rural settings may have worse surgical outcomes, including mortality rates, compared with urban populations. Methods: Pediatric patients, from birth to 18 years old, who had surgery from January 1, 2011, to December 31, 2021, at a single Children's Hospital were included in the study. Data was obtained from the provincial Operating Room Information System (ORIS) database. Postal code, rural and urban status, distance to children's hospital (0-50 km, 51-100 km, 101-150 km, 151-200 km, and >200 km), and procedure urgency were collected. 30-day mortality for all procedures was collected. Results: 85,998 surgical procedures were performed at ACH between 2011 and 2021. 17,773 (20.7%) of patients lived >50 km or more from the hospital - 5,329 (6.2%) 51- 100 km, 4,053 (4.7%) 101-150 km, n=2,323 (2.7%) 151-200 km, and 6,070 (7.1%) >200 km. Rural patients had higher 30-day mortality rates than urban patients, with an odds ratio of mortality (rural vs urban) of 2.30 (95% CI, 0.95 to 5.60). When stratified by distance, patients living closer to the hospital (0-50 km) had lower odds of mortality. Conclusions: Canadian Rural patients have higher operative mortality risks than urban patients. This study identifies a vulnerable group of patients who do not have equal access to care and may experience worse outcomes. (c) 2024 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).

Introduction To improve surgical quality and safety, health systems must prioritise equitable care for surgical patients. Racialised patients experience worse postoperative outcomes when compared with non-racialised surgical patients in settler colonial nation-states. Identifying preventable adverse outcomes for equity-deserving patient populations is an important starting point to begin to address these gaps in care. To derive literature-based estimates of the outcome gap for racialised surgical patients, we will systematically review and meta-analyse rates of adverse postoperative events associated with common and/or high-risk operations performed in Canada and the USA.Methods and analysis An electronic search of Medline, Embase, Web of Science, Cochrane Central, CINAHL and Scopus will be conducted to identify studies reviewing complication rates of racialised compared with non-racialised patients from inception to December 2023. We will include publications from the USA and Canada comparing surgical outcomes of racialised and non-racialised patients. The procedures of interest will be the four most common (hip arthroplasty, knee arthroplasty, appendectomy and cholecystectomy), and the five highest risk (oesophagectomy, abdominal aortic aneurysm, aortic valve replacement, coronary artery bypass graft and pancreatectomy) surgical procedures performed in these countries. The outcomes will be mortality, length of stay in hospital, readmission, reoperation, wound dehiscence, surgical site infection, pulmonary embolism, sepsis or septic shock, pneumonia, blood transfusion, stroke, myocardial infarction and bile duct injury. Summary estimates of cumulative incidence, prevalence, incidence rate and occurrence rate of complications using DerSimonian and Laird random effects models will be calculated for the systematic review and meta-analysis. Heterogeneity in these estimates will be examined using subgroup analyses and meta-regression.Ethics and dissemination This study uses secondary data and, therefore, does not require ethics approval. This study will be communicated through presentations at international conferences and published in peer-reviewed literature. The results from this study will inform the development of future surgical equity tools and quality improvement programmes and provide benchmarks on the impact of racism on surgical outcomes.PROSPERO registration number CRD42024491439.

BACKGROUND:Pediatric liver tumors are predominantly primary malignant tumors, and complete tumor resection with sufficient preservation of liver tissue is crucial for improving prognosis. However, due to the delicate anatomical structure of the pediatric liver and the relatively large size of the tumors, especially in difficult cases, the surgical challenges are substantial. While precision liver surgery are widely applied in clinical practice, pediatric cases require more customized approaches. The application of three-dimensional (3D) visualization technology is crucial for enhancing surgical accuracy, allowing for precise preoperative planning and intraoperative guidance. METHODS:This consensus was collaboratively developed by 36 experts from eight countries, using the Glaser's state-of-the-art method to review and refine the draft. RESULTS:The final consensus resulted in 15 international multidisciplinary consensus recommendations on clinical application of 3D visualization in precision surgery for pediatric liver tumors. CONCLUSION:This consensus will standardize the application of 3D visualization technology in precision surgery for pediatric liver tumors to improve outcomes and reduce risks.

Surgical disease is one of the most costly and morbid areas of health care and, perhaps, the most amenable to improvement through well-designed and well-implemented tools. Preventable adverse events have been successfully targeted by tools such as the Surgical Safety Checklist. However, health system priorities related to surgery have evolved; the concepts of what constitutes quality care have changed over time. How efficiency and access contribute to safe care, where equity exists as a key outcome measure, and the central role of the patient in defining good care have changed the way we look at surgical priorities. This review of Canadian surgical priorities provides a unique perspective on how we should consider national strategies for surgical safety by exploring both nationally published data as well as the priorities set by provincial and governmental agencies that extend beyond traditional clinical metrics.

BACKGROUND:Adverse events in health care are frequently discussed in morbidity and mortality conferences. However, while health care has evolved to be delivered by interprofessional teams, morbidity and mortality conferences have been slow to include all team members. One particularly potent barrier to conducting an interprofessional team-based morbidity and mortality conference is a lack of psychological safety among team members. Clinicians from various professions bring differences in perspectives, culture, perceived hierarchy, and assumptions about other professions. These perspectives may bring value to the interprofessional team-based morbidity and mortality conferences, but they may also degrade psychological safety. METHODS:This report explores the link between professional silos and psychological safety among the health care team in the context of an interprofessional team-based morbidity and mortality conference using the perioperative space as an example. The authors draw on the concept of team fault lines-a potential division along a team members' characteristics that can divide a group or team into subgroups. The roots of perioperative professional silos, which define these fault lines, are then traced to the historical context of the health care professions, the individual development of professional identities, and the role of organizations in maintaining these silos. From these observations, a framework for describing these foundations is proposed, which the authors use to evaluate the broader teamwork-in-health-care literature to generate specific recommendations to promote psychological safety in team-based morbidity and mortality conferences. CONCLUSION:This framework can be used to postulate strategies for improving the ability for teams to learn from morbidity and mortality conferences. However, future work remains in implementing and studying these recommendations.

BACKGROUND:Mobile health (mHealth) platforms are being used to understand patient-reported experiences before and after surgery. Currently, there is limited literature describing the feasibility of using mHealth to evaluate patient experience among older adults. The objective of this study was to determine the feasibility of using mHealth to evaluate patient-reported outcomes among patients older and younger than 65 years undergoing elective colectomy for diverticulitis. METHODS:A prospective pilot study was performed between June 1, 2020 and August 31, 2021, enrolling patients aged > 18 years undergoing elective colectomy for diverticulitis at a single academic center (n = 62). A Health Insurance Portability and Accountability Act-compliant mHealth platform was used to deliver patient-reported quality-of-life surveys at 3 time points: preoperatively, 3 months postoperatively, and 6 months postoperatively. The primary outcome was the feasibility of using mHealth in patients older and younger than 65 years to collect outcomes using recruitment, engagement, and survey completion rates. Preliminary findings of patient experiences were evaluated for patients older and younger than 65 years as secondary outcomes. RESULTS:Overall, 33.9% of participants were older than 65 years with a median age of 59.8 years (IQR, 53.3-67.9). mHealth enrollment was high (100%) with survey response rates of 79% preoperatively, 64.5% at 3 months postoperatively, and 17.7% at 6 months postoperatively. Response rates were similar among patients older and younger than 65 years (P = .79 preoperatively and P = .39 at 3 months postoperatively). CONCLUSION:Utilization of mHealth to evaluate patient-reported outcomes is feasible in the preoperative and early postoperative settings, including older adults undergoing elective surgery for diverticulitis. Future work will focus on improving long-term outcomes to better examine potential differences when considering patient-centered outcomes among older adult patients.