# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Now in its centennial year since inauguration, the Department of Surgery at the University of Toronto lays claim to more than 500 faculty, 270 residents, and 250 clinical fellows. There are 7 direct entry residency training programs, and 4 subspecialty programs accredited by the Royal College of Physicians and Surgeons of Canada. There have been 10 chairs of the department since 1921. This article chronicles the life and times of the previous chairs in sequence; the success of the department originates from its many talented and luminary surgeons who have innovated and shaped their fields of surgery. In recent years, the department's academic productivity has been characterized by more than 1400 peer-reviewed publications per year, and annual research grant capture in excess of $90 million. Since the time of William Gallie, surgical trainees have been enabled to develop careers in surgery and science through the Gallie Program and, more recently, the Surgeon Scientist Training Program (SSTP) to attain higher graduate degrees. Providing quaternary surgical care at multiple hospital sites in Toronto, the Department of Surgery takes great pride in its robust clinical fellowship programs across all specialties that continue to attract trainees from around the world.

McLeod, Robin S. MD∗; Moore, Ernest E. MD†; Crozier, John A. FRACS‡; Civil, Ian D. MBChB§; Ahmed, Najma MD, PhD∗; Bulger, Eileen M. MD¶; Stewart, Ronald M. MD|| Author Information

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Department Surgery, University of Toronto, Toronto, Ontario, Canada. [email protected]. The authors report no conflicts of interests.

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.

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.

Objective: The development of patient education (PE) materials is costly and resource-intensive, and no mechanisms exist for sharing materials across cancer centers/hospitals to limit duplicated effort. The aim of this study was to explore the incidence and cost implication of duplicated PE efforts. Methods: PE leaders from all (14) cancer centers in Ontario, Canada, submitted their collections of systemic therapy PE materials. Materials were categorized by topic and were coded as duplicate (more than one other material exists on the same topic and there was significant content and/or textual overlap), adapted (material was adapted from an existing material) or unique (no other material addresses the topic). Results: 304 materials were included and <50 % of materials had duplicate content (n = 166, 55 %), a small proportion were adapted (n = 27, 9%), and less than half were unique (n = 111, 37 %). The majority of materials were considered amenable to adaptation meaning that the content was not dependent on a specific institutional context (n = 283, 93 %). The opportunity for cost savings if duplication of effort could be avoided is approximately $800 K for systemic therapy materials produced in cancer centers. Conclusion: There is need to refine the process for developing PE materials. Creating mechanisms of sharing can help facilitate equal access to materials and can result in significant cost savings. Practice Implications: Efforts are needed to better coordinate the development of PE materials among patient educators. Better coordination would allow patient education programs to focus on other important challenges. (c) 2020 Elsevier B.V. All rights reserved.

Purpose: Currently, Canada is the only G8 country without a proton beam therapy (PBT) facility in operation or under construction. Based on experience from other G8 countries with PBT facilities, it has been estimated that approximately 5-16% of all cancer patients who receive radiation treatment with curative intent should be considered for PBT. To begin planning for a PBT facility in Ontario, a more robust and localized estimate of the need for PBT is required. Methods: An expert panel was assembled to develop an estimate of the need for PBT services. A step-wise approach was taken to: 1) identify clinical indications for PBT; 2) obtain volume estimates for curative photon therapy for select practice site groups and patient subpopulations (pediatric, adolescent young adult and adult); 3) develop and apply clinical algorithms to estimate the proportion of each indication that should be considered for PBT. Data was gathered from program level reporting and published literature. Expert opinion and consensus further informed decision-making. Results: 13 practice site groups for which PBT could have potential clinical benefit were identified: benign neoplasms, breast, central nervous system, endocrine, gastrointestinal, genitourinary, gynecological, hematology, head and neck, lung, other cancers, sarcoma, and skin. The largest variation in practice site estimates across subpopulations were found in endocrine, breast, gastrointestinal, sarcoma, and skin. Applying expert panel proportion estimates to curative radiation treatment volumes gathered from program level reporting for the respective practice groups and subpopulations (n=27,500), the estimated provincial need for PBT is 1,542 (5.6%) patients per year, with a lower bound of 364 (1.32%) and an upper bound of 4,246 (15.44%). Conclusions: An Ontario PBT facility has the potential to provide equitable access to comprehensive cancer care; decreasing long-term toxicities, improving patient experience and health outcomes. With limited published data in the Canadian context of an estimated need for Proton Beam Therapy, the methodology described provides a more robust estimate of the need for PBT. This methodology can be applied across other jurisdictions to assist with PBT planning exercises.

The study aim was to evaluate the costs associated with developing and reviewing patient education materials (pamphlets) across Ontario cancer centers. While patient education often produces a positive return on investment, limited efforts have been dedicated to optimizing the personnel, time, and capital dedicated to this feat across healthcare systems. Patient education leaders at 14 cancer centers completed a survey measure, estimating the number of hours spent developing and reviewing pamphlets and identifying the personnel involved in each procedural step. The time expended per center in each step was then combined with average salary data for the identified personnel to derive total cost estimates. Cancer centers spend on average $5672 (SD = $3180) developing (M = $4560, SD = $2620) and reviewing (M = $1112, SD = $654) one pamphlet. This cumulates to an average per annum spending of $65,401 (SD = $75,494) for pamphlet development and $19,819 (SD = $28,524) for annual pamphlet review at each cancer center. The cost and number of hours spent developing and reviewing pamphlets varied substantially between cancer centers. While the security of budgets for patient education varies across cancer centers, opportunities to optimize human capital and monetary resources should be considered. Results of the study can be used to advocate for sustainable investment into cancer education programs, improve the coordination of educational materials production and review, and ensure that resource quality and access are consistent across the province.

802 Background: Perioperative anemia is common in gastrointestinal (GI) cancer surgery patients and is often treated with red blood cell transfusion (RBCT), which carries risks for inferior oncologic outcomes. Despite level-1 evidence for restrictive transfusion strategies, RBCT use is often not consistent with guidelines leading to a high rate of unnecessary transfusions. Understanding of RBCT use at the population-level is necessary to develop system-level efforts to minimize perioperative RBCT for cancer. We sought to evaluate the secular trends of transfusion in a large North American population. Methods: We conducted a population-based retrospective cohort study of patients undergoing GI cancer resection between 2007-2018 using linked administrative health datasets in Ontario, Canada. Primary outcome was administration of any RBCT during the hospitalization. Temporal RBCT trends were analyzed with Cochran-Armittage tests for trend. Modified Poisson regression assessed trends while controlling for potential confounders. Results: Of 79,764 patients undergoing GI cancer resection, median age was 69 (IQR: 60-78) years old and 55.5% were male. The most frequent cancer site was colorectal cancer (n = 63,243), followed by esophago-gastric (n = 7,307), hepato-pancreato-biliary (n = 6,510), and small bowel (n = 2,704). 30% of patients received RBCT. The proportion of patients transfused decreased from 26.5% in 2007 to 18.9% in 2018 (p < 0.001). This trend remained consistent when stratified by sex, age, cancer type, operative approach, procedure setting, and institution teaching status. After adjusting for patient and institution factors, the time period was associated with receipt of RBCT with a relative risk of 0.94 (95% CI 0.91-0.96) for 2011-14 and 0.75 (95% CI 0.73-0.78) for 2015-2018 compared to the period of 2007-10. Conclusions: Over the 11-year study period, we observed a decrease in RBCT for GI cancer resection. These findings may reflect the dissemination of clinical guidelines and implementation of patient blood management programs. An evaluation of institutional variation and the relationship with outcomes is warranted to identify opportunities for further improvement.

41 Background: Provider experience and physician burnout has been recognized as a critical issue in medicine. Ontario, Canada has a single payer cancer system run by Ontario Health (Cancer Care Ontario) with a mandate covering system level planning and delivery of cancer services, funding, and quality improvement. As part of a larger provincial initiative to address clinician burnout, we examined the prevalence and drivers of burnout in practicing physician oncologists in Ontario. Methods: In November-December 2019, surgical, medical, hematological, and radiation oncologists in Ontario were invited to complete an anonymous online survey to assess burnout and its drivers. Burnout prevalence was assessed through the Maslach Burnout Inventory – Human Services Survey for Medical Personnel (MBI-HSS MP). Data on demographic, workplace, engagement, and practice profiles were collected. Logistic regression modeling was conducted to assess key variables associated with “high” burnout using a common definition of high scores on the MBI subscales of emotional exhaustion (EE) (> 27) and/or depersonalization (DP) (>10). Results: Response rate to the survey was 44% (n=418) with 72% reporting high levels of burnout. Mean scores for EE (30.7, SD 12.1) and DP (9.9, SD 6.7) were consistent with high burnout. Participants endorsed known drivers of burnout including: 1) a poor culture of wellness at work (e.g., not comfortable talking to leadership (72%), 2) inefficiencies of practice (e.g. feeling insufficient documentation time (67%)) and 3) personal resilience (e.g. not feeling they are contributing professionally in ways they value (21%)). Age (<45yrs) (OR: 2.15), poor/marginal control over workload (OR: 4.42), feeling used/unappreciated (OR: 2.63), working atmosphere that feels hectic/chaotic (OR: 2.68), and insufficient time for documentation requirements (OR: 2.52) significantly impacted the odds of high burnout in the regression model (p<0.05). Conclusions: The high rate of burnout among oncology physicians in a single payer public cancer system in Ontario is concerning for the wellbeing of providers, patients and system sustainability. Drivers important for maintaining a culture of wellness and efficiency of practice will require local, regional and provincial health policy to improve. Next steps will include raising awareness with provincial initiatives/policy to address key burnout drivers, and examining the impact of working under pandemic conditions (Covid-19) on oncologist burnout.

Background Overprescribing of opioids to patients following surgery is a public health concern, as unused pills may be diverted and contribute to opioid misuse and dependence. The objectives of this study were to determine current opioid-prescribing patterns for common surgical procedures, factors that affect surgeons’ prescribing behaviour and their perceived ability to manage patients with opioid use disorder. Methods Survey participants included all consultant and trainee surgeons at the University of Toronto. The survey, which was administered electronically, included 52 multiple-choice, rank-order and open-text questions eliciting information on current prescribing patterns, prescribing of adjunct pain medications, and education and other factors related to opioid prescribing. Staff surgeons were also asked about how they manage patients with a suspected opioid issue. Results Eighty surgical trainees and 40 staff surgeons responded to the survey (response rate 32%). Five staff surgeons (12%) felt adequately educated to prescribe pain medications (including opioids) at discharge. Staff surgeons prescribed Tylenol 3 more frequently than other opioids. Twenty (51%) of 39 staff surgeons reported that they sought further help for their patients when an opioid use disorder was suspected. Conclusion Our results support existing studies showing a large degree of variability in postoperative opioid prescribing. Institutional guidelines have been shown to be effective in curbing excessive opioid prescribing without increasing unnecessary emergency department visits for uncontrolled pain. Thus, there is an opportunity to develop institutional guidelines to educate surgical teams in the prescribing of opioids and about services available for patients with a substance use disorder.

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.

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.

AbstractBackgroundIn Ontario, FOLFIRINOX (FFX) and gemcitabine + nab‐paclitaxel (GnP) have been publicly funded for first‐line unresectable locally advanced pancreatic cancer (uLAPC) or metastatic pancreatic cancer (mPC) since April 2015. We examined the real‐world effectiveness and safety of FFX vs GnP for advanced pancreatic cancer, and in uLAPC and mPC.MethodsPatients receiving first‐line FFX or GnP from April 2015 to March 2017 were identified in the New Drug Funding Program database. Baseline characteristics and outcomes were obtained through the Ontario Cancer Registry and other population‐based databases. Overall survival (OS) was assessed using Kaplan‐Meier and weighted Cox proportional hazard models, weighted by the inverse propensity score adjusting for baseline characteristics. Weighted odds ratio (OR) for hospitalization and emergency department visits (EDV) were estimated from weighted logistic regression models.ResultsFor 1130 patients (632 FFX, 498 GnP), crude median OS was 9.6 and 6.1 months for FFX and GnP, respectively. Weighted OS was improved for FFX vs GnP (HR = 0.77, 0.70‐0.85). Less frequent EDV and hospitalization were observed in FFX (EDV: 67.8%; Hospitalization: 49.2%) than GnP (EDV: 77.7%; Hospitalization: 59.3%). More frequent febrile neutropenia‐related hospitalization was observed in FFX (5.8%) than GnP (3.3%). Risk of EDV and hospitalization were significantly lower for FFX vs GnP (EDV: OR = 0.68, P = .0001; Hospitalization: OR = 0.76, P = .002), whereas the risk of febrile neutropenia‐related hospitalization was significantly higher (OR = 2.12, P = .001). Outcomes for uLAPC and mPC were similar.ConclusionIn the real world, FFX had longer OS, less frequent all‐cause EDV and all‐cause hospitalization, but more febrile neutropenia‐related hospitalization compared to GnP.

Background: Barriers exist in implementing enhanced recovery after surgery (ERAS), which aims to decrease postoperative complication rates and length of stay, because perioperative care is varied and compliance from a multidisciplinary team is critical to success. The objectives of this project were to evaluate the effectiveness of the National Surgical Quality Improvement Program (NSQIP) database as a tool for the ongoing assessment of outcomes associated with ERAS and to evaluate ERAS as a quality-improvement strategy at a hospital-wide level. Methods: Adult patients who underwent an elective colorectal procedure at The Ottawa Hospital between March 2010 and September 2015 were included. Information on demographic characteristics, functional status, medical background, procedure details and hospital length of stay (LOS) was abstracted from the NSQIP database. We compared data on outcomes (LOS, postoperative complications, unplanned return visits to the emergency department and 30-day mortality) before and after ERAS. Results: We analyzed data for 609 patients (318 [52.2%] colon resection, 291 [47.8%] rectal resection; 190 [31.2%] before ERAS, 419 [68.8%] after ERAS). Significantly more patients were discharged within 5 days of surgery after ERAS than before (43.5% v. 29.1%, p < 0.05), and LOS more than 10 days was also reduced (23.7% v. 24.9%, p < 0.001). Implementation of ERAS was associated with an absolute reduction of 12% in postoperative complications and a significant reduction in surgical site infections among patients who underwent open procedures (p = 0.04). Conclusion: The introduction of an ERAS program for monitoring standardized perioperative care facilitates a data-driven approach to guide implementation of practice guidelines and establish the sustainability of ERAS protocols and data collection processes.