Same-day discharge is safe and feasible following POEM surgery for esophageal motility disorders.

INTRODUCTION: Per-oral endoscopic myotomy (POEM) is an effective treatment for achalasia and other esophageal dysmotility disorders. Current practices surrounding post-operative care involve admission and routine esophagogram prior to discharge. This study aims to establish the safety and feasibility of same-day discharge following POEM. METHODS: Retrospective analysis of prospectively collected data for patients who underwent POEM between November 2013 and June 2019 at a single institution in Ontario, Canada. Patients were discharged home on the same day with controlled pain, when tolerating clear fluids. Patients were admitted if clinically indicated. Esophagography was initially a systematic practice prior to discharge, but later only performed when clinically indicated. Emergency department visits and hospital admissions within 90 days were assessed. RESULTS: In total, 90 patients underwent a successful POEM procedure. A total of 72 patients (79.1%) were discharged on the same day, 14 patients (15.4%) were discharged home the following day, and 5 patients (5.5%) experienced longer admissions to hospital. One POEM was unsuccessful. 22 (24.2%) patients had adverse events, leading to 8 (8.8%) unplanned admissions, with one patient requiring prolonged admission for esophageal leak, identified clinically. Fifty-three patients underwent routine esophagography while part of our protocol, with no identified leak, which prompted our change in practice to only perform esophagography when clinically indicated. In the 90-day post-procedure, ten patients visited the emergency department, of which seven were re-admitted, five for POEM-related issues. Our mean Eckhardt score at 2 weeks was 2.1 from 7.2 preoperatively. CONCLUSION: This study establishes that same-day discharge is both safe and feasible following POEM and suggests that esophagography should be performed only when clinically indicated. This represents a shift from the routine practice of admission and imaging for patients undergoing POEM, encouraging the transition to outpatient POEM procedures.

A Longitudinal Analysis of Wait Times for Bariatric Surgery in a Publicly Funded, Regionalized Bariatric Care System.

BACKGROUND: Bariatric surgery is proven to be the most effective strategy for management of obesity and its related comorbidities. However, in Canada, patients awaiting bariatric surgery can be subjected to prolonged wait times, thereby subjecting them to increased morbidity and mortality, as well as decreased psychosocial well-being. OBJECTIVE: To assess the factors associated with prolonged wait times for bariatric surgery within a publicly funded, provincial bariatric network. METHODS: This was a retrospective population-based study of all patients aged > 18 years who were referred for bariatric surgery from April 2009 to May 2015 using linked administrative databases to capture patient demographic data, socioeconomic variables, healthcare utilization, and institutional factors. The main outcome of interest was a wait time greater than 18 months. Multivariate logistic regression modeling was used to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: A total of 18,854 patients underwent bariatric surgery from April 2009 to December 2016, of which 2407 patients experienced wait times of > 18 months. On average, yearly wait times have increased for patients receiving surgery with wait times of 10.98 months (SD 5.48) in 2010 and 13.09 (SD 6.69) in 2016 (p < 0.001). Increasing age (OR 1.12, 95% CI 1.05-1.19, p = 0.0004), BMI (OR 1.08, 95% CI 1.04-1.11, p < 0.001), and male gender (OR 1.47, 95% CI 1.28-1.70, p < 0.001) were significantly associated with increased bariatric surgery wait times. Additionally, smoking status (OR 1.46, 95% CI 1.09-1.97, p = 0.0118) and obesity-related comorbidities particularly diabetes (OR 1.29, 95% CI 1.14-1.44, p < 0.001) and heart failure (OR 1.72, 95% CI 1.43-2.07, p < 0.001) were correlated with prolonged wait times for surgery. Socioeconomic variables including disability (OR 1.64, 95% CI 1.38-1.92, p < 0.001) and immigration status (OR 1.35, 95% 1.11-1.64, p = 0.003) were correlated with increased odds of longer wait times, as were regions with regionalized assessment and treatment centres (RATC) when referenced against centers of excellence (COEs) in number of days added with 20.45 (95% CI 13.20-27.70, p < 0.001). CONCLUSION: Wait times for bariatric surgery in a publicly funded, regionalized bariatric program are influenced by certain patient characteristics, socioeconomic variables, and institutional factors. This warrants further intervention and study to help improve these inequities when encountering potentially vulnerable populations awaiting bariatric surgery.

Concussion diagnosis and management: Knowledge and attitudes of family medicine residents.

OBJECTIVE: To assess the knowledge of, attitudes toward, and learning needs for concussion diagnosis and management among family medicine residents. DESIGN: E-mail survey. SETTING: University of Toronto in Ontario. PARTICIPANTS: Family medicine residents (N = 348). MAIN OUTCOME MEASURES: To describe relationships between awareness of concussion management and lifestyle, education background, and residency placement, t tests and 2 tests were used as appropriate. Linear regression was used to compare self-reported concussion knowledge with knowledge scores. Thematic analysis was used to interpret answers to the qualitative question asking residents to describe challenges they foresee physicians facing when diagnosing and managing concussion. RESULTS: The residents who responded (n = 73, response rate 21%) correctly answered an average of 5.2 questions out of 9 (58%) regarding the diagnosis and management of concussion. Postgraduate year, sex, personal history of concussion, and clinical exposure to concussion were not significant factors in predicting the number of correct answers. Several misconceptions and knowledge gaps were revealed. Of residents who responded, 71% did not recognize chronic traumatic encephalopathy and only 63% recognized second-impact syndrome as consequences of repetitive concussions. Moreover, 32% of residents did not think that every individual with a concussion should see a physician as part of management. Knowledge scores did not predict self-reported concussion knowledge. Thematic analysis revealed 4 themes related to the challenges of concussion diagnosis and management: the nonspecificity and vagueness of symptoms, lack of formal diagnostic criteria, patient compliance with management, and counseling patients with respect to return to play, work, or learning. CONCLUSION: We found substantial gaps in knowledge surrounding concussion diagnosis and management among family medicine residents. This lack of knowledge should be addressed at both the undergraduate medical education level and the residency training level to improve concussion-related care and patient outcomes.