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.

INTRODUCTION:Despite advances in antiretroviral therapy (ART), surgical outcomes in people with HIV (PWH) remain poorly understood. This study compared postoperative outcomes and healthcare use between PWH and matched people without HIV (non-PWH) undergoing general surgery in British Columbia, Canada. METHODS:Linked HIV-related and health administrative data (Jan 2008-Mar 2020) identified PWH and matched non-PWH. Outcomes included 30-day readmissions, 30-day re-operations, 30-day mortality, one-year mortality, and healthcare utilization. RESULTS:Among 1252 PWH and 5008 non-PWH, HIV status was not associated with odds of 30-day readmissions, re-operations, or deaths. However, PWH had higher odds of mortality within one year post op (OR 1.75, 95% CI: 1.12-2.73), shorter hospital stays (RR 0.64, 95% CI: 0.55-0.73), higher likelihood of lab (RR 2.11, 95% CI: 1.86-2.39), and specialist visits (RR 1.16, 95% CI: 1.01-1.35) compared to non-PWH. CONCLUSION:PWH experienced similar short-term outcomes but higher one-year mortality and distinct care patterns, suggesting factors beyond perioperative care influence outcomes.

Language and cultural barriers may impede effective communication and delay prompt surgical intervention for immigrants undergoing emergency general surgery (EGS). Timely surgical care for immigrants may be further impacted by additional challenges during overnight encounters due to reduced staffing and support systems. This study aims to compare in-hospital wait times for EGS and possible prolonged overnight encounters among immigrants and non-immigrants in British Columbia (BC), Canada. This study analyzed population-level immigration data linked with hospital and emergency department records for patients undergoing EGS procedures from 2013 to 2021. In-hospital wait times, tracked as time from triage-to-assessment and assessment-to-admission, were compared between immigrants and non-immigrants and between recent (< 2 years since immigration) and established (> 10 years since immigration) immigrants. The proportion of off-hour presentations were compared between immigrants and non-immigrants. The study included 77,937 EGS procedures between 2013 and 2021, 14.3

Immigrants to Canada face unique barriers that result in them accessing publicly funded healthcare services differently than non-immigrants. These barriers are particularly critical in the context of Emergency General Surgery (EGS) where timely access to healthcare is essential for better health outcomes. This study compares preoperative healthcare utilization between immigrants undergoing EGS with non-immigrants. EGS procedures in British Columbia between 2013 and 2021 were analyzed using population-based linked immigration, physician billing, and hospital discharge summary data. Preoperative primary care visits, specialist consults, imaging, and emergency department (ED) visits in the one-year period preceding the EGS were compared between immigrants with non-immigrants. Sub-analyses examined years since immigration and ethnic minority status. Of 77,937 EGS procedures, immigrants accounted for 14.6%. Immigrants had fewer pre-operative primary care visits (RR: 0.94, 95%CI: 0.92-0.96), specialist consults (RR: 0.88, 95%CI: 0.85-0.91), imaging services (RR: 0.96, 95%CI: 0.93-0.99), and ED visits (RR: 0.70, 95%CI: 0.68-0.72). Within the immigrant cohort, fewer primary care and ED visits were observed among the newest immigrants and among ethnic minorities. Immigrants accessed fewer healthcare services in the period preceding their EGS. Differences were most pronounced among new immigrants and immigrants from culturally-diverse countries who may be unfamiliar with the structure or processes for accessing healthcare services. Policy interventions are needed to prospectively link immigrants at highest risk of EGS with appropriate health services.

Background: Canada's growing immigrant population faces language and cultural barriers that hinder timely access to healthcare. The balance between elective and emergency general surgery (EGS) reflects immigrant's access to healthcare since many EGS cases are avoidable through treatment as elective procedures. Objective: This study examines whether immigrants are more likely to undergo EGS than non-immigrants and measures whether language proficiency or access to primary care plays a role in disparity in access to care. Methods: All general surgery procedures performed in British Columbia, Canada between 2013 and 2021 were identified using a population-based longitudinal administrative data that linked immigration data with physician billing and hospital data. The primary outcome was whether patients' surgery was elective or EGS and the primary exposure was immigrant status. The odds of EGS between immigrants and non-immigrants was estimated adjusting for patient and system-level differences. The analysis compared immigrants with and without English proficiency on arrival to Canada. Results: Of 237,054 general surgery procedures, 30.7 % were EGS and 15.2 % involved immigrants. Immigrants had slightly higher odds of undergoing emergency general surgery (EGS) than non-immigrants. Immigrants not fluent in English had 16 % higher odds of EGS (OR: 1.16, 95 %CI 1.03-1.32). Immigrants with fewer GP contacts were more likely to undergo EGS (45.5 % versus 42.2 %, p < 0.01). Conclusions: Immigrants with language barriers and who accessed primary care less often were more likely to require EGS. These findings highlight the need for system-level interventions to reduce immigrants' reliance on emergency surgical care.

INTRODUCTION:Advances in HIV care have dramatically reduced perioperative mortality, challenging outdated beliefs about worse outcomes for people with HIV (PWH). This study aims to compare odds of developing infections and wound complications in PWH versus non-PWH controls undergoing general surgery. METHODS:A data linkage between the British Columbia (BC) HIV-treatment database and hospital administrative data was used to identify PWH, and matched non-PWH who underwent general surgery in BC, Canada between 2008 and 2020. Post-operative infections and wound complications within 30 days were identified using ICD)-9/10 codes. RESULTS:Among 1252 PWH and 5008 matched non-PWH, HIV status was not significantly associated with post-operative infection (OR:0.95, 95 %CI:0.78-1.16) or wound complications (OR:1.07, 95 %CI:0.19-6.00). However, PWH on income assistance (OR:1.57, 95 %CI:1.26-1.95), with a substance use disorder (OR:1.38, 95 %CI:1.08-1.77) or IV drug use (OR:2.90, 95 %CI:2.28-3.69) had higher odds of post-operative infection. CONCLUSION:HIV status alone does not increase the likelihood of post-operative infections or wound complications. However, socioeconomic factors such as being on income assistance and having substance use history likely impact these risks.

BACKGROUND:We measured changes in self-reported health and symptoms attributable to rectal prolapse surgery using patient-reported outcome (PRO) measures. METHODS:A prospectively recruited cohort of patients scheduled for rectal prolapse repair in Vancouver, Canada between 2013 and 2021 were surveyed before and 6-months after surgery using seven PROs: the EuroQol Five-Dimension Instrument (EQ-5D-5L), Generalized Anxiety Disorder Scale (GAD-7), Pain Intensity, Interference with Enjoyment of Life and General Activity (PEG), Patient Health Questionnaire (PHQ-9), Fecal Incontinence Severity Index (FISI), Gastrointestinal Quality of Life Index (GIQLI), and the Fecal Incontinence Quality of Life Scale (FIQL). RESULTS:We included 46 participants who reported improvements in health status (EQ-5D-5L; p ​< ​0.01), pain interference (PEG; p ​< ​0.01), depressive symptoms (PHQ-9; p ​= ​0.01), fecal incontinence severity (FISI; p ​< ​0.01), gastrointestinal quality of life (GIQLI; p ​< ​0.01), and fecal incontinence quality of life (FIQL) related to lifestyle (p ​= ​0.02), coping and behaviour (p ​= ​0.02) and depression and self-perception (p ​= ​0.01). CONCLUSION:Surgical repair of rectal prolapse improved patients' quality of life with meaningful improvements in fecal incontinence severity and pain, and symptom interference with daily activities.

Introduction The role for routine thymectomy in patients with secondary or tertiary hyperparathyroidism (SHPT, THPT) is unclear. We aim to compare rates of recurrence and complications in patients who underwent subtotal parathyroidectomy with and without thymectomy. Methods Patients who underwent surgery for renal HPT at a tertiary endocrine surgery center between 2010 and 2022 were reviewed. Presence of parathyroid tissue in resected tissue was identified through pathology reports. A multivariate logistic regression was used to compare baseline characteristics, recurrence rates and complications between those who did and did not undergo thymectomy. Results Of 107 patients who underwent subtotal parathyroidectomy, 29 (27.1%) underwent concomitant thymectomy. Recurrence occurred in 15 patients (14%). Thymectomy did not affect recurrence (OR: 0.33, 95%CI: 0.06-1.28, p=0.14), but was associated with permanent hypoparathyroidism (OR: 4.62, 95%CI: 1.67-13.18, p=0.003). Fewer parathyroid specimens increased the odds of thymectomy (p=0.04). Parathyroid glands were found in 6 thymectomy samples (20.7%). Conclusion Thymectomy at the time of subtotal parathyroidectomy for renal HPT was not associated with disease recurrence, but increased likelihood of permanent hypoparathyroidism.

INTRODUCTION:This study investigated the separate impacts of diet and pre-operative antibiotics on gut microbiome and colonic anastomotic healing using a mouse model. METHODS:Male C57BL/6J mice were fed either low-fat-high-fibre (SD) or high-fat-low-fiber (WD) groups for 6 weeks, then further received either pre-operative antibiotics or a control sham before a colonic anastomotic procedure was performed. After 7 days, the anastomosis was assessed and microbiota composition and biodiversity were analyzed in anastomotic tissue and stool. RESULTS:WD-fed mice had shorter survival (5.2 ​± ​2.3 vs. 6.9 ​± ​2.3 days, p ​= ​0.022), increased weight loss (5.55 ​± ​3.80g vs. 2.65 ​± ​2.36g, p ​= ​0.03), and reduced biodiversity compared to SD-fed mice. Pre-operative antibiotics improved anastomotic healing scores (1.33 ​± ​0.65 vs. 2.08 ​± ​0.79, p ​= ​0.02) and reduced Enterococcus faecalis growth in tissue and stool (p ​= ​0.02, p ​= ​0.02). Improved anastomotic healing correlated with lower Enterococcus abundance (p ​= ​0.04) and higher collagen III and IV levels (p ​= ​0.01, 0.04) in anastomotic tissue. CONCLUSION:SD promotes enhanced post-operative recovery and increased microbiome biodiversity, while pre-operative antibiotics enhance anastomotic healing by suppressing Enterococcus faecalis growth, mitigating collagen III/IV degradation.

BACKGROUND:We aimed to investigate the prevalence, characteristics, and management of nephrolithiasis in primary hyperparathyroidism (PHPT) patients. METHODS:Medical records of patients who underwent parathyroidectomy at a tertiary care hospital in British Columbia from January 2016 to April 2023 were retrospectively reviewed. Demographic data, laboratory results, imaging reports, and urologic consultations were examined. Descriptive statistics and relevant statistical tests, including logistic regressions, were utilized for data analysis. RESULT:Of the 413 PHPT patients included in the study population, 41.9% harbored renal stones, and nearly half (48.6%) required urological interventions. Male sex, elevated preoperative serum ionized calcium (iCa) and 24-h urinary calcium (24 ​h urine Ca) levels were independent risk factors for stone formation. Additionally, male sex, younger age, and lower preoperative serum 25-hydroxyvitamin D (25(OH)D) level were associated with higher odds of requiring urological intervention for stones. CONCLUSIONS:This study identified significant prevalence of asymptomatic renal calcifications in PHPT patients, with a substantial proportion necessitating urological intervention. These findings emphasize the importance of incorporating screening and treatment of renal stones into the management of PHPT patients.

Background: We aimed to investigate the association of preoperative calcium and parathyroid hormone (PTH) levels with sensitivity and accuracy of dual energy computed tomography (DECT), single-photon emission CT with Tc-99m-sestamibi (CT-MIBI), and ultrasound (US) for pre-operative localization primary hyperparathyroid (PHP) patients. Methods: Patients undergoing parathyroidectomy for PHP at a tertiary care facility who underwent DECT, CT-MIBI and US between 2012 and 2021 were stratified by preoperative calcium and PTH levels. Results: Of 278 patients, those with high calcium and PTH levels had a higher sensitivity and accuracy with DECT (87.7%, 85.2%) compared to CT-MIBI (82.3%, 79.0%), and US (61.7%, 53.1%). DECT was more sensitive and accurate than other preoperative localization techniques in subgroups with normal PTH (DECT sensitivity 60.9%, accuracy 52.1%) and normal calcium levels (41.7%, 33.3%). Conclusion: Preoperative calcium and PTH were associated with sensitivity and accuracy of pre-operative localization in PHP. DECT was sensitive and accurate for preoperative localization compared to other first-line imaging techniques.

Skin sparing mastectomy (SSM) with immediate breast reconstruction (IBR) is a safe option for curative-intent surgical resection, but medial location of the tumor has associated with increased risk of local recurrence. We investigate the factors associated with recurrence in individuals with medial breast cancers who underwent SSM with IBR. One hundred thirty-six individuals were included in our cohort, and factors associated with recurrence included increasing tumor stage, transverse rectus abdominis muscle flap reconstruction, prior breast surgery, and prior radiation therapy. This suggests that women with medial breast cancers undergoing SSM with IBR who have these risk factors may be at higher risk for recurrence.Background: Skin sparing mastectomy (SSM) with immediate breast reconstruction (IBR) has been established as a safe option for curative-intent surgical resection. Prior studies have shown that medial location of the primary tumor is associated with increased risk of local recurrence. The purpose of this study is to determine the factors associated with recurrence and survival in individuals with breast cancers located in the inner quadrants (medial) who underwent SSM with IBR. Methods: A retrospective chart review was done on individuals with medial breast cancer who received SSM with IBR in British Columbia between 1980 and 2012. Results: Of 136 individuals with medial breast cancer undergoing SSM with IBR, 27.9% experienced local recurrence and 42.6% overall recurrence. Factors associated with recurrence were T-stage (44.8 vs. 22.4% with T2 disease, P = .02), transverse rectus abdominis muscle (TRAM) flap reconstruction (48.3 vs. 29.5%, P = .00395), prior breast surgery (87.9 vs. 63%, P = .002), and prior radiation therapy (74.1 vs. 38.5%, P < .0001). LR was associated with higher mortality (OR 2.78, 95% CI: 1.26-6.09). Conclusion: For patients with medial tumors undergoing SSM with IBR, potential risk factors for recurrence are T-stage, TRAM flap reconstr uction, pr ior breast surgery, and prior radiation therapy. Local recurrence is associated with poor survival.Clinical Breast Cancer, Vol. 23, No. 8, 876-881 (c) 2023 Elsevier Inc. All rights reserved.

Beliefs regarding the cause of acute appendicitis are commonly based on classic surgical teachings that suggest it occurs due to appendiceal luminal obstruction that is caused by fecaliths, lymphoid hyperplasia, infectious agents such as parasites, foreign bodies and tumors. This short communication presents a contemporary overview of the etiology of appendicitis based on current literature.

Background: The incidence of adverse perioperative cardiac complications after parathyroidectomy has not been well described. This study aimed to evaluate the incidence of perioperative chest pain and cardiac complications after parathyroidectomy and to evaluate risk factors that may identify patients who are more likely to benefit from a cardiac workup. Methods: We performed a retrospective study of all patients undergoing parathyroidectomy for primary hyperparathyroidism by a single endocrine surgeon at a tertiary endocrine centre between 2011 and 2018. Patient demographics, clinicopathologic variables, operative and postoperative details (reported chest pain, performance of a cardiac workup and new postoperative cardiac diagnosis) were reviewed. Patients with chest pain were compared to those without chest pain using the Fisher exact test and Student t test. Results: Fourteen of 295 patients (4.7%) reported chest pain in the immediate postoperative period. Most patients were investigated with a 12-lead electrocardiogram and troponin (n = 12/14), yet none were diagnosed with a cardiac event. When comparing patients with and without chest pain, there was no significant difference in age, gender, body mass index, presence of cardiovascular risk factors, American Society of Anesthesiologists score or length of surgery. Conclusion: Postoperative chest pain after parathyroidectomy is not an uncommon event and leads to a cardiac workup in most cases; however, the risk of significant postoperative cardiac events is minimal. In the “choosing wisely” era, one should evaluate each patient’s pretest probability of such events and avoid extensive workup in low-risk patients to avoid unnecessary costs to the health care system.