Laparoscopic subtotal cholecystectomy for the difficult gallbladder: Evolution of technique at a single teaching hospital.

BACKGROUND: We have developed an algorithmic approach to laparoscopic cholecystectomy, including subtotal cholecystectomy, as a bailout strategy when the Critical View of Safety cannot be safely achieved due to significant inflammation and fibrosis of the hepatocystic triangle. METHODS: This is a retrospective cohort study comparing postoperative outcomes in patients with severe cholecystitis who underwent laparoscopic cholecystectomy or laparoscopic subtotal cholecystectomy at St. Joseph's Health Centre from May 2016 to July 2021, as well as against a historical cohort. We further stratified laparoscopic subtotal cholecystectomy cases based on fenestrating or reconstituting subtype. RESULTS: The cohort included a total of 105 patients who underwent laparoscopic cholecystectomy and 31 patients who underwent laparoscopic subtotal cholecystectomy. Bile leaks (25.8% vs 1.0%, relative risk 3.5, 95% confidence interval 3.5-208.4) were more common in the laparoscopic subtotal cholecystectomy group. Postoperative endoscopic retrograde cholangiopancreatography (22.6% vs 3.8%, relative risk 5.9, 95% confidence interval 1.9-18.9) and biliary stent insertion (19.4% vs 1.0%, relative risk 20.3, 95% confidence interval 2.5-162.5) were also more common in the laparoscopic subtotal cholecystectomy group. Bile leaks in laparoscopic subtotal cholecystectomy were only documented in the fenestration subtype, most of which were successfully managed with endoscopic retrograde cholangiopancreatography and biliary stenting. Compared to our previous study of laparoscopic cholecystectomy and subtotal cholecystectomy for severe cholecystitis between 2010 and 2016, there has been a decrease in postoperative laparoscopic cholecystectomy complications, subtotal cholecystectomy cases, and no bile duct injuries. CONCLUSION: Following our algorithmic approach to safe laparoscopic cholecystectomy has helped to prevent bile duct injury. Laparoscopic cholecystectomy remains the gold standard for the management of severe cholecystitis; however, in extreme cases, laparoscopic subtotal cholecystectomy is a safe bailout strategy with manageable morbidity.

Thinking Your Way Through a Difficult Laparoscopic Cholecystectomy: Technique for High-Quality Subtotal Cholecystectomy.

Laparoscopic subtotal cholecystectomy (LSC) is a bailout strategy to prevent bile duct injury in difficult gallbladder cases. It is associated with acceptable morbidity that is readily managed with postoperative interventions. Here we share our techniques for LSC. We begin with landmarking, which includes the line of safety, a theoretical line the sulcus of Rouvière and the junction of the cystic and hilar plates. If the fundus can be grasped, then the gallbladder is dissected off the cystic plate using the top-around approach. The gallbladder is then amputated, creating a short cuff of proximal gallbladder. This cuff can be left patent (2A) or cinched close with an ENDOLOOP (Ethicon) if it is small, ideally less than 1 cm (1A). If the fundus cannot be grasped, then an inverted T incision is made on the anterior gallbladder wall. The longitudinal incision is extended toward the fundus, and the transverse incision is extended superiorly along the cystic plate edge. Two "bunny ears" are developed and ultimately resected to excise the anterior gallbladder wall at an oblique angle while leaving the posterior wall intact (2B). If the remaining cuff is small, then it can be sutured closed against the gallbladder back wall (1B). In the setting of extensive bowel adhesion to the anterior gallbladder, we perform a fundectomy, from which we extend two incisions along the cystic plate to open the gallbladder like a clamshell. Our paper describes and illustrates our St Joseph's Health Centre institutional LSC approach and subtype classification (1A, 1B, 2A, and 2B).

High Risk Breast Cancer Screening is a Double Edged Sword: A Qualitative Study of Patient Perspectives on the Ontario High Risk Breast Cancer Screening Program.

BACKGROUND: MRI-based breast cancer screening for high-risk women has been associated with false positives. This study explored the benefits and drawbacks of MRI-based screening using in-depth patient interviews. METHODS: This was a qualitative study of interviews with women participating in the High Risk Ontario Breast Screening Program. Women enrolled at two centers who had completed at least one round of screening were invited to participate. Recruitment was suspended when thematic saturation was reached. Semi-structured telephone interviews were conducted and transcribed verbatim. Emergent themes were identified and a coding framework established. RESULTS: 21 women (median age 41 years) participated in telephone interviews. Women had been in the program a median of 4 years (IQR 1-5), and 71% had experienced at least one abnormal screen. Eight participants (38%) had undergone biopsies. Six women (29%) were BRCA mutation carriers. MRIs were described as intimidating, uncomfortable, and claustrophobic. Participants were concerned about long-term exposure to gadolinium contrast. Compared to MRI, mammography alone was viewed as painful, less sensitive, and a "useless…waste of time." MRI provided a "psychological safety net" that outweighed the distress associated with abnormal screens. Many women accepted this trade-off as a "two-edged sword" that was "worth it" and provided a sense of control. Suggestions for improvement included more information regarding the risks of MRI, and access to counselling. CONCLUSIONS: Women participating in MRI-based screening strongly value reassurance from a highly sensitive screening test. This outweighed the distress of abnormal screens. There are areas for improvement around patient communication and psychosocial support.

Total Kidney Volume Measurements in ADPKD by 3D and Ellipsoid Ultrasound in Comparison with Magnetic Resonance Imaging.

BACKGROUND AND OBJECTIVES: Total kidney volume is a validated prognostic biomarker for autosomal dominant polycystic kidney disease. Total kidney volume by magnetic resonance imaging (MRI) and manual segmentation is considered the "reference standard," but it is time consuming and not readily accessible. By contrast, three-dimensional (3D) ultrasound provides a promising technology for total kidney volume measurements with unknown potential. Here, we report a comparative study of total kidney volume measurements by 3D ultrasound versus the conventional methods by ultrasound ellipsoid and MRI ellipsoid. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This single-center prospective study included 142 patients who completed a standardized 3D ultrasound and MRI. Total kidney volumes by 3D ultrasound and ultrasound ellipsoid were compared with those by MRI. We assessed the agreement of total kidney volume measurements by Bland-Altman plots and misclassification of the Mayo Clinic imaging classes between the different imaging methods, and we assessed prediction of Mayo Clinic imaging classes 1C-1E by average ultrasound kidney length >16.5 cm. RESULTS: Compared with MRI manual segmentation, MRI ellipsoid, 3D ultrasound, and ultrasound ellipsoid underestimated total kidney volume (mean difference: -3%, -9%, and -11%, respectively), with Mayo Clinic imaging classes misclassified in 11%, 21%, and 22% of patients, respectively; most misclassified cases by MRI ellipsoid (11 of 16), 3D ultrasound (23 of 30), and ultrasound ellipsoid (26 of 31) were placed into a lower Mayo Clinic imaging class. Predictions of the high-risk Mayo Clinic imaging classes (1C-1E) by MRI ellipsoid, 3D ultrasound, and ultrasound ellipsoid all yielded high positive predictive value (96%, 95%, and 98%, respectively) and specificity (96%, 96%, and 99%, respectively). However, both negative predictive value (90%, 88%, and 95%, respectively) and sensitivity (88%, 85%, and 94%, respectively) were lower for 3D ultrasound and ultrasound ellipsoid compared with MRI ellipsoid. An average ultrasound kidney length >16.5 cm was highly predictive of Mayo Clinic imaging classes 1C-1E only in patients aged ≤45 years. CONCLUSIONS: Total kidney volume measurements in autosomal dominant polycystic kidney disease by 3D ultrasound and ultrasound ellipsoid displayed similar bias and variability and are less accurate than MRI ellipsoid. Prediction of high-risk Mayo Clinic imaging classes (1C-1E) by all three methods provides high positive predictive value, but ultrasound ellipsoid is simpler to use and more readily available.

Benefits of dexmedetomidine on postoperative analgesia after bariatric surgery.

INTRODUCTION: Anesthetic management of morbidly obese patients is challenging, particularly in those undergoing bariatric surgery. Dexmedetomidine is a α2-adrenergic receptor agonist that is increasingly used in the perioperative setting for its beneficial properties including sedation, anxiolysis, analgesia with opioid-sparing effects, and minimal impact on respiration. The objective of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia and recovery-related outcomes among patients undergoing bariatric surgery. EVIDENCE ACQUISITION: We conducted a systematic review and meta-analysis of MEDLINE, EMBASE, and CENTRAL databases from conception to September 2021 for randomized controlled trials (RCTs) using dexmedetomidine in bariatric patients on postoperative outcomes. Outcomes were pooled using random effects model and presented as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI). EVIDENCE SYNTHESIS: In total, 20 RCTs with 665 patients in the dexmedetomidine group and 671 patients in the control groups were included. Among RCTs, the dexmedetomidine group had significantly lower opioid usage at 24-hours postoperatively (MD: -5.14, 95% CI: -10.18 to -0.10; moderate certainty), reduced pain scores on a 10-point scale at PACU arrival (MD: -1.69, 95% CI: -2.79 to -0.59; moderate certainty) and six hours postoperatively (MD: -1.82, 95% CI: -3.00 to -0.64; low certainty), and fewer instances of nausea (RR: 0.59, 95% CI: 0.45 to 0.75; moderate certainty) and vomiting (RR: 0.25, 95% CI: 0.15 to 0.43; moderate certainty), compared to control groups. CONCLUSIONS: Dexmedetomidine is an efficacious anesthesia adjunct in patients undergoing bariatric surgery. These benefits of dexmedetomidine may be considered in the multi-modal analgesic management and enhanced recovery pathways in this high-risk population.

Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury.

BACKGROUND: Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program. STUDY DESIGN: Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored. RESULTS: Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences. CONCLUSIONS: An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

Strengths and weaknesses in the methodology of survey-based research in surgery: A call for standardization.

BACKGROUND: Survey-based studies are often the basis of policy changes; however, the methodologic quality of such research can be questionable. Methodologic reviews of survey-based studies have been conducted in other medical fields, but the surgical literature has not been assessed. METHODS: All citations published in 9 major surgical journals from 2002 to 2019 were screened for studies administering surveys to health care professionals. Descriptive and methodologic data were collected by 2 reviewers who also assessed the transparency and quality of the methodology. Agreement between reviewers was assessed using a weighted κ-statistic. Survey quality metrics were measured, descriptive statistics were calculated, and regression analysis was used to assess the association between subjective overall study quality and objective quality metrics. RESULTS: We included 271 articles in our analysis; the weighted-κ for reviewer quality assessment was 0.69 and for transparency assessment was 0.71. Deficiencies were identified in questionnaire development methodology and reporting, in which the median number of developmental steps reported was 1 (of 8) and in the reporting of incomplete/missing data where 63% of studies failed to report how incomplete questionnaires were managed; 70% of studies failed to report missing data. Overall subjective quality was positively associated with objective quality metrics. CONCLUSION: The deficiencies identified in the surgical literature highlight the need for improvement in the conduct and reporting of survey-based research, both in the surgical literature and more broadly. Adoption of a standardized reporting guideline for survey-based research may ameliorate the deficiencies identified by this study and other investigations.

Evaluation of the effectiveness of the Global Medical Student Partnership program in undergraduate medical education.

BACKGROUND: The Global Medical Student Partnership (GMSP) is a medical student-led international initiative to promote accessible global health learning. This study aims to evaluate the effectiveness of the GMSP program in meeting its learning objectives. METHODS: Canadian and international medical student pairs met online monthly (January-May 2018) to discuss global health-related medical cases. Students then reviewed cases with local GMSP peers and faculty experts. A mixed-methods study was performed to evaluate whether the objectives of the program had been achieved. 26 of 32 (81.3%) students completed a questionnaire, and 13 (40.6%) also participated in one-on-one semi-structured interviews. Descriptive statistics and thematic analysis were used to analyze students' perspectives on skill development through GMSP. RESULTS: GMSP students agreed or strongly agreed that international collaboration and communication skills were more important to them following program participation (92.3%, 92.3% respectively). Many expressed that after GMSP, they knew more about their healthcare system, practices abroad and how to solve complex health issues (92.3%, 84.6%, 61.5% respectively). Qualitative data showed GMSP improved students' communication and presentation skills, provided a foundation for international relationships, fostered appraisal of diverse health systems, and furthered students' understanding of health advocacy. CONCLUSIONS: Our findings demonstrate that GMSP met its original objectives by providing students with opportunities to engage in international collaborations and to further develop their skills in advocacy, communication, and health-systems research. This program may be an important addition to medical education as it makes use of technology and peer-to-peer exchange to enable global health learning.

CONTEXTE: Le Global Medical Student Partnership (GMSP) est une initiative d'envergure internationale menée par des étudiants en médecine qui vise à favoriser la formation en santé mondiale. La présente étude consiste à évaluer l'efficacité du programme GMSP pour atteindre ses objectifs d'apprentissage. MÉTHODOLOGIE: Des paires d'étudiants en médecine canadiens et étrangers se sont rencontrés en ligne tous les mois, entre janvier et mai 2018, pour discuter de situations cliniques en santé mondiale. Après la rencontre, ces situations cliniques ont été revues par des pairs locaux du programme GMSP et des experts du corps professoral. On a effectué une étude à devis mixte pour déterminer si les objectifs du programme avaient été atteints. 26 des 32 (81,3 %) étudiants ont répondu à un questionnaire et 13 (40,6 %) ont aussi pris part à des entrevues individuelles semi-dirigées. Des statistiques descriptives et une analyse thématique ont été utilisées analyser les perceptions des étudiants sur le développement d'habiletés par le programme GMSP. RÉSULTATS: Les étudiants participant au programme GMSP étaient d'accord ou très en accord pour dire que les habiletés à la collaboration internationale et à la communication étaient plus importantes à leurs yeux après la participation au programme (92.3%, 92,3%, respectivement). Bon nombre ont affirmé qu'après le programme GMSP, ils en connaissaient plus sur leur système de soins de santé, les pratiques à l'étranger et les façons de résoudre des problèmes de santé complexes (92,3 %, 84,6 %, 61,5 % respectivement). Des données qualitatives ont montré que le programme GMSP a amélioré les aptitudes à la communication et des techniques de présentation. Elles ont servi à établir des relations à l'international, à évaluer divers systèmes de soins de santé et à mieux comprendre la promotion de la santé et à militer en faveur de celle-ci. CONCLUSIONS: Nos résultats montrent que le programme GMSP a atteint ses objectifs de départ puisqu'il a donné aux étudiants des occasions de collaboration internationale et leur a permis de développer davantage leurs habiletés en matière de défense des droits, de communication, et de recherche sur les systèmes de soins de santé. Ce programme pourrait s'avérer un important complément à la formation médicale parce qu'il utilise la technologie et des échanges pairs-pairs pour l'apprentissage des enjeux de santé mondiaux.

Exploring the Impact of a Mobile Health Solution for Postpartum Pelvic Floor Muscle Training: Pilot Randomized Controlled Feasibility Study.

BACKGROUND: The postpartum period is a vulnerable time for the pelvic floor. Early implementation of pelvic floor muscle exercises, appropriately termed as pelvic floor muscle training (PFMT), in the postpartum period has been advocated because of its established effectiveness. The popularity of mobile health (mHealth) devices highlights their perceived utility. The effectiveness of various mHealth technologies with claims to support pelvic floor health and fitness is yet to be substantiated through systematic inquiry. OBJECTIVE: The aim of this study was to determine the acceptability, feasibility, and potential effect on outcomes of an mHealth device purposed to facilitate pelvic floor muscle training among postpartum women. METHODS: A 16-week mixed methods pilot study was conducted to evaluate outcomes and determine aspects of acceptability and feasibility of an mHealth device. All participants received standardized examination of their pelvic floor muscles and associated instruction on the correct performance of PFMT. Those randomized to the iBall intervention received instructions on its use. Schedules for utilization of the iBall and PFMT were not prescribed, but all participants were informed of the standard established recommendation of PFMT, which includes 3 sets of 10 exercises, 3 to 4 times a week, for the duration of the intervention period. Quantitative data included the measurement of pelvic floor muscle parameters (strength, endurance, and coordination) following the PERFECT assessment scheme: Incontinence Impact Questionnaire scores and the Urogenital Distress Inventory (UDI-6) scores. Aspects of acceptability and feasibility were collected through one-to-one interviews. Interview transcripts were analyzed using Thorne's interpretive description approach. RESULTS: A total of 23 women with a mean age of 32.2 years were randomized to an intervention group (n=13) or a control group (n=10). Both groups improved on all measures. The only statistically significant change was the UDI-6 score within both groups at 16 weeks compared with baseline. There was no statistically significant difference between the intervention group and control group on any outcomes. Most participants using the iBall (n=10, 77%) indicated value in the concept of the mHealth solution. Technical difficulties (n=10, 77%), a cumbersome initiation process (n=8, 61%), and discomfort from the device (n=8, 61%) were reasons impeding intervention acceptability. Most participants (n=17, 74%) indicated that the initial assessment and training was more useful than the mHealth solution, a tenet that was echoed by all control group participants. CONCLUSIONS: Our pilot study demonstrated the potential for mHealth solution-enhanced PFMT in the early postpartum period. Usability issues in hardware and software hindered feasibility and acceptance by the participants. Our findings can inform the redesign of mHealth solutions that may be of value if acceptability and feasibility issues can be overcome. TRIAL REGISTRATION: ClinicalTrials.gov NCT02865954; https://clinicaltrials.gov/ct2/show/NCT02865954.

A diaper bank and home visiting partnership: Initial exploration of research and policy questions.

OBJECTIVES: The cost of diapering an infant can place a significant financial strain on families living in poverty. Partnerships between diaper banks and home visiting programs for young families may offer an innovative solution to expanding the reach and impact of diaper banks in low-income communities. The purpose of this pilot study was to uncover preliminary information about the functions of diaper distribution through home visiting programs, and to inform future research and policy questions regarding diaper distribution to families in need. DESIGN AND SAMPLE: In this descriptive qualitative pilot study, semi-structured interviews were conducted with 6 home visitors from Minding the Baby® (MTB), a home visiting intervention for young parents. MTB clinicians routinely distribute diapers in partnership with The Diaper Bank in Connecticut. We used directed content analysis to code and analyze interview transcripts. RESULTS/CONCLUSION: These preliminary findings indicate that partnerships between home visiting programs and diaper banks may benefit families by improving diaper access, reducing stigma, and fostering trusting relationships with home visitors. Home visiting program benefits including engagement or re-engagement with families may need to be balanced with potential effects on clinical and therapeutic relationships. Recommendations for next steps in research and related policy questions are discussed.

Colorimetric approach to high-throughput mutation analysis.

High-throughput genomic mutation screening for primary tumors has characteristically been expensive, labor-intensive, and inadequate to detect low levels of mutation in a background of wild-type signal. We present a new, combined PCR and colorimetric approach that is inexpensive, simple, and can detect the presence of 1% mutation in a background of wild-type. We compared manual dideoxy sequencing of p53 for eight lung cancer samples to a novel assay combining a primer extension step and an enzymatic colorimetric step in a 96-well plate with covalently attached oligonucleotide sequences. For every sample, we were able to detect the presence or absence of the specific mutation with a statistically significant difference between the sample optical density (OD) and the background OD, with a sensitivity and specificity of 100%. This assay is straightforward, accurate, inexpensive, and allows for rapid, high-throughput analysis of samples, making it ideal for genomic mutation or polymorphism screening studies in both clinical and research settings.