A survey of management preferences for bladder exstrophy and cloacal anomalies among Canadian pediatric surgeons and urologists.

PURPOSE: This study examined the current referral patterns and preferences of Canadian Association of Paediatric Surgeons (CAPS) and Pediatric Urologists of Canada (PUC) members for management of bladder exstrophy and cloacal anomalies (BECA). METHODS: We invited CAPS and PUC members to participate in an online survey using RedCap. Demographic variables, years in practice, current referral patterns and local expertise at the participants' institution were collected. Participants' preferences towards three distinct referral models were assessed using Likert scales: no centralization of care, centralization in one or two national centres of excellence, or a consortium-based approach. RESULTS: There were 82 survey respondents (2/3 were CAPS members, 35.4% female, 72% in practice for >10 years). Although >90% of participants agreed/somewhat agreed that surgical volumes impact outcomes, 58% reported not referring out BECA patients for treatment; about 50% recognized the existence of a local dedicated expert. In terms of referral preferences, 84% of participants favoured identification of a few centres with expertise based on geographic location (a consortium-based approach), while only 7% chose a one or two national centres of excellence model. Over half of participants agreed/somewhat agreed with participating in trials of a consortium-based approach in Canada. CONCLUSION: Most CAPS and PUC members do not refer BECA patients elsewhere for treatment. Nonetheless, most surgeons recognize the importance of volume to improve outcomes and show willingness to participate in trials to concentrate experience; most participants favour a consortium-based approach through identification of a few centres of excellence based on geographic location.

Avoiding initial hypothermia does not improve liver graft quality in a porcine donation after circulatory death (DCD) model of normothermic perfusion.

BACKGROUND: Normothermic machine perfusion (NMP) of liver grafts donated after circulatory death (DCD) has shown promise in large animal and clinical trials. Following procurement, initial flush with a cold preservation solution is the standard of care. There is concern that initial cooling followed by warming may exacerbate liver injury, and the optimal initial flush temperature has yet to be identified. We hypothesize that avoidance of the initial cold flush will yield better quality liver grafts. METHODS: Twenty-four anaesthetized pigs were withdrawn from mechanical ventilation and allowed to arrest. After 60-minutes of warm ischemia to simulate a DCD procurement, livers were flushed with histidine-tryptophan-ketoglutarate (HTK) at 4°C, 25°C or 35°C (n = 4 per group). For comparison, an adenosine-lidocaine crystalloid solution (AD), shown to have benefit at warm temperatures in heart perfusions, was also used (n = 4 per group). During 12-hours of NMP, adenosine triphosphate (ATP), lactate, transaminase levels, and histological injury were determined. Bile production and hemodynamics were monitored continuously. RESULTS: ATP levels recovered substantially following 1-hour of NMP reaching pre-ischemic levels by the end of NMP with no difference between groups. There was no difference in peak aspartate aminotransferase (AST) or in lactate dehydrogenase (LDH). Portal vein resistance was lowest in the 4°C group reaching significance after 2 hours (0.13 CI -0.01,0.277, p = 0.025). Lactate levels recovered promptly with no difference between groups. Comparison to AD groups showed no statistical difference in the abovementioned parameters. On electron microscopy the HTK4°C group had the least edema with mean cell thickness of 2.92µm (p = 0.41) while also having the least sinusoidal dilatation with a mean diameter of 5.36µm (p = 0.04). For AD, the 25°C group had the lowest mean cell thickness at 3.14µm (p = 0.09). CONCLUSIONS: Avoidance of the initial cold flush failed to demonstrate added benefit over standard 4°C HTK in this DCD model of liver perfusion.

Factors Affecting the Development of Confidence Among Surgical Trainees.

OBJECTIVE: The objective of this study was to explore and better characterize the factors affecting confidence during surgical training. DESIGN: This was a qualitative research study in which we conducted semistructured interviews with surgical residents to explore factors affecting their confidence. SETTING: This study was conducted at the University of Alberta Hospital, a tertiary care center located in Edmonton, Alberta, Canada. PARTICIPANTS: Residents from the University of Alberta General Surgery residency program were invited to participate from each postgraduate year (PGY) 2, 3, and 4 for a total of 7 participants (3 PGY-2, 3 PGY-3, and 1 PGY-4; 3 male, and 4 female). We excluded residents who had completed or were currently enrolled in dedicated research years. RESULTS: Resident confidence was found to be influenced by internal and external factors operating before, during, and after a particular surgical task. Internal factors incorporated personal experiences (including operative experience), personal expectations, self-perception, and individual skill development. External factors involved feedback, patient outcomes, relationships with staff, and working within a supportive environment. Interestingly, residents discussed external social factors more than case volume, technical skills, or underlying knowledge. Residents did not feel that their personal lives (e.g. marital status or having children) directly affected their surgical confidence. Regardless of the factor itself, positive experiences helped build and maintain confidence by providing feelings of reassurance, encouragement, comfort, and acceptance. CONCLUSIONS: Surgical confidence is influenced by a range of internal and external factors. Understanding these factors can help educators improve learning experiences for residents and accelerate their progress towards being confident, independent surgeons.

Oral feeding outcomes in infants with esophageal atresia and tracheoesophageal fistula.

PURPOSE: The purpose of this study was to explore oral feeding outcomes in infants born with type-C esophageal atresia and tracheoesophageal fistula (EA/TEF). METHODS: A retrospective cohort study of all infants born between January 2005 and December 2015 undergoing surgery for type-C EA/TEF at the University of Alberta Hospital was performed. RESULTS: Fifty-seven infants were identified, of which 61.4% were exclusively orally feeding at discharge home. Variables anticipated to predict oral feeding were explored. Only 46% of babies with a structural cardiac anomaly had exclusive oral feeding compared to 79% without cardiac anomaly, p=0.055. Logistic regression identified the presence of structural cardiac anomaly and corrected gestational age at discharge as significant negative predictor variables for exclusive oral feeding at discharge home. Additional regression analyses found early transanastomotic feeding to be a significant positive predictor for the discontinuation of PN. CONCLUSION: We report the rate of oral feeding at discharge for infants born with type-C EA/TEF and identify predictor variables. This information is important for health care professionals and the families of children born with EA/TEF, because a significant number will go home with supplemental nutrition by gavage tube or other routes. LEVEL OF EVIDENCE: Level 2.

Perioperative factors predicting poor outcome in elderly patients following emergency general surgery: a multivariate regression analysis.

BACKGROUND: Older adults (≥ 65 yr) are the fastest growing population and are presenting in increasing numbers for acute surgical care. Emergency surgery is frequently life threatening for older patients. Our objective was to identify predictors of mortality and poor outcome among elderly patients undergoing emergency general surgery. METHODS: We conducted a retrospective cohort study of patients aged 65-80 years undergoing emergency general surgery between 2009 and 2010 at a tertiary care centre. Demographics, comorbidities, in-hospital complications, mortality and disposition characteristics of patients were collected. Logistic regression analysis was used to identify covariate-adjusted predictors of in-hospital mortality and discharge of patients home. RESULTS: Our analysis included 257 patients with a mean age of 72 years; 52% were men. In-hospital mortality was 12%. Mortality was associated with patients who had higher American Society of Anesthesiologists (ASA) class (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.43-10.33, p = 0.008) and in-hospital complications (OR 1.93, 95% CI 1.32-2.83, p = 0.001). Nearly two-thirds of patients discharged home were younger (OR 0.92, 95% CI 0.85-0.99, p = 0.036), had lower ASA class (OR 0.45, 95% CI 0.27-0.74, p = 0.002) and fewer in-hospital complications (OR 0.69, 95% CI 0.53-0.90, p = 0.007). CONCLUSION: American Society of Anesthesiologists class and in-hospital complications are perioperative predictors of mortality and disposition in the older surgical population. Understanding the predictors of poor outcome and the importance of preventing in-hospital complications in older patients will have important clinical utility in terms of preoperative counselling, improving health care and discharging patients home.

CONTEXTE: La population qui connaît la croissance la plus rapide est celle des adultes âgés (≥ 65 ans). Ces personnes nécessitent un nombre croissant d'interventions chirurgicales urgentes. Or, la chirurgie d'urgence comporte souvent un risque de décès pour les patients âgés. Notre objectif était d'identifier les prédicteurs de la mortalité et d'une issue négative chez les patients âgés soumis à une chirurgie générale d'urgence. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective chez des patients de 65 à 80 ans soumis à une chirurgie générale d'urgence entre 2009 et 2010 dans un centre de soins tertiaires. Nous avons recueilli les données démographiques, les comorbidités, les complications perhospitalières, la mortalité et les détails sur l'état général de santé des patients. Nous avons utilisé l'analyse de régression logistique afin de dégager les prédicteurs ajustés en fonction des covariables pour la mortalité perhospitalière et les congés hospitaliers des patients vers leur domicile. RÉSULTANTS: Notre analyse a regroupé 257 patients âgés en moyenne de 72 ans; 52 % étaient des hommes. La mortalité perhospitalière a été de 12 %. La mortalité a été associée à des patients qui se classaient dans une catégorie ASA (American Society of Anesthesiologists) plus élevée (rapport des cotes [RC] 3,85, intervalle de confiance [IC] de 95 % 1,43­10,33, p = 0,008) et présentaient plus de complications perhospitalières (RC 1,93, IC de 95 % 1,32­2,83, p = 0,001). Près des deux tiers des patients qui ont reçu leur congé pour retourner à la maison étaient plus jeunes (RC 0,92, IC de 95 % 0,85­0,99, p = 0,036), se classaient dans une catégorie ASA moins élevée (RC 0,45, IC de 95 % 0,27­ 0,74, p = 0,002) et avaient connu moins de complications perhospitalières (RC 0,69, IC de 95 % 0,53­0,90, p = 0,007). CONCLUSION: La catégorie ASA et les complications perhospitalières sont des prédicteurs périopératoires de mortalité et d'état général de santé dans la population âgée soumise à la chirurgie. Comprendre les prédicteurs d'une issue négative et l'importance de prévenir les complications perhospitalières chez les patients âgés aura une importante utilité clinique pour les consultations préopératoires, l'amélioration des soins de santé et le retour des patients à la maison.

Randomized trial of success of pediatric anesthesiologists learning to use two video laryngoscopes.

OBJECTIVES: The primary purpose of this study was to establish the ability of pediatric anesthesiologists to learn to use two video laryngoscopes - the GlideScope(®) system (GS) and the Karl Storz Direct Coupled Interface, DCI(®), (KS). BACKGROUND: The number of intubation attempts required to attain proficiency with a video laryngoscope is not known. METHODS: Baseline intubation times, using direct laryngoscopy, were determined for each anesthesiologist on 20 children. Anesthesiologists were then randomized to perform 20 intubations with the GS or KS before crossing over to the other device. RESULTS: There were 193 successful intubations and eight failed intubations (4.0%) with the GS. Median time-to-intubation with the GS for each anesthesiologist ranged from 24.5 to 32.8 s. There were 193 successful intubations and three failed intubations (1.5%) with the KS (P > 0.05 vs failed attempts with GS). Median time-to-intubation with the KS ranged from 21.9 to 31.1 s. For both the GS and KS, five of eight anesthesiologists met the study definition of 'Success'. There was no correlation between median time-to-intubation with all laryngoscopes combined and years since completion of training. The distribution of Cormack and Lehane scores was almost identical for the GS and KS; there were fewer grade III or IV scores than with direct laryngoscopy (P = 0.03; Fischer's exact test). Mean and median times on intubation no. 16-20 were shorter for the KS than for the GS. CONCLUSIONS: Although only 65% of anesthesiologists attained the stringent study definition of 'Success', all rapidly leaned to use both video laryngoscopes.