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BackgroundSuturing is a fundamental skill in undergraduate medical education. It can be taught by faculty-led, peer tutor-led, and holography-augmented methods; however, the most educationally effective and cost-efficient method for proficiency-based teaching of suturing is yet to be determined.MethodsWe conducted a randomized controlled trial comparing faculty-led, peer tutor-led, and holography-augmented proficiency-based suturing training in pre-clerkship medical students. Holography-augmented training provided holographic, voice-controlled instructional material. Technical skill was assessed using hand motion analysis every ten sutures and used to construct learning curves. Proficiency was defined by one standard deviation within average faculty surgeon performance. Intervention arms were compared using one-way ANOVA of the number of sutures placed, full-length sutures used, time to proficiency, and incremental costs incurred. Surveys were used to evaluate participant preferences.ResultsForty-four students were randomized to the faculty-led (n = 16), peer tutor-led (n = 14), and holography-augmented (n = 14) intervention arms. At proficiency, there were no differences between groups in the number of sutures placed, full-length sutures used, and time to achieve proficiency. The incremental costs of the holography-augmented method were greater than faculty-led and peer tutor-led instruction ($247.00 ± $12.05, p < 0.001) due to the high cost of the equipment. Faculty-led teaching was the most preferred method (78.0%), while holography-augmented was the least preferred (0%). 90.6% of students reported high confidence in performing simple interrupted sutures, which did not differ between intervention arms (faculty-led 100.0%, peer tutor-led 90.0%, holography-augmented 83.3%, p = 0.409). 93.8% of students felt the program should be offered in the future.ConclusionFaculty-led and peer tutor-led instructional methods of proficiency-based suturing teaching were superior to holography-augmented method with respect to costs and participants’ preferences despite being educationally equivalent.

Background Prophylactic drainage following pancreaticoduodenectomy (PD) reduces morbidity and mortality. Little evidence exists to advise on whether passive gravity (PG) or active suction (AS) drainage systems result in superior outcomes. This study examines the relationship between drainage system and morbidity following PD. Methods All patients undergoing elective PD with an operatively placed drain in the 2016 ACS-NSQIP database were included. Pre- and intra-operative factors were examined. Multivariable logistic regression and coarsened exact matching (CEM) were used to assess for an association between drainage system (PG vs. AS) and morbidity. The primary outcome was postoperative pancreatic fistula (POPF). Results In total, 3430 patients were included: 563 (16.4%) with PG and 2867 (83.6%) with AS drainage system. On multivariable regression, 1787 patients were included. Drainage type was not associated with POPF, surgical site infection, delayed gastric emptying, or re-operation. AS drainage was protective against percutaneous drain insertion (OR 0.65, 95% CI 0.44–0.96, p  = 0.033). In the CEM cohort ( n  = 268), superficial SSI was higher in the AS group (0.8% vs. 6.0%, p  = 0.036). There was a trend toward higher rates of composite total SSI (PG 15.7%, AS 23.9%, p  = 0.092) and organ space SSI (PG 14.2%, AS 20.2%, p  = 0.195) in the AS group; this did not demonstrate statistical significance. Conclusions The findings of this study suggest that AS drainage is protective against percutaneous drain insertion, but may be associated with increased risk of SSI. There was no relation between drainage type and POPF. A prospective, randomized controlled trial is warranted to further explore these findings.

Postoperative pancreatic fistula (POPF) is a major source of morbidity following pancreatic resection. Surgically placed drains under suction or gravity are routinely used to help mitigate the complications associated with POPF. Controversy exists as to whether one of these drain management strategies is superior. The objective was to identify and compare the incidence of POPF, adverse events, and resource utilization associated with passive gravity (PG) versus active suction (AS) drainage following pancreatic resection. MEDLINE, EMBASE, CINAHL, and Cochrane Library databases were searched from inception to May 18, 2020. Outcomes of interest included POPF, post-pancreatectomy hemorrhage (PPH), surgical site infection (SSI), other major morbidity, and resource utilization. Descriptive qualitative and pooled quantitative meta-analyses were performed. One randomized control trial and five cohort studies involving 10 663 patients were included. Meta-analysis found no difference in the odds of developing POPF between AS and PG ( p  = 0.78). There were no differences in other endpoints including PPH ( p  = 0.58), SSI (wound p  = 0.21, organ space p  = 0.05), major morbidity ( p  = 0.71), or resource utilization ( p  = 0.72). The risk of POPF or other adverse outcomes is not impacted by drain management following pancreatic resection. Based on current evidence, a suggestion cannot be made to support the use of one drain over another at this time. There is a trend toward increased intra-abdominal wound infections with AS drains ( p  = 0.05) that merits further investigation.

Background The COVID-19 pandemic placed increased pressure to discharge patients early; this could have resulted in rushed discharges requiring patients to return to hospital. The impact of the pandemic on readmission after colorectal surgery is unknown. Methods The National Surgical Quality Improvement Program (ACS-NSQIP) database was used to compare patients undergoing elective colorectal surgery in 2019 and 2020, prior to and during the COVID-19 pandemic. Multivariable logistic regression was used to examine variables associated with readmission. Propensity score matching was then used to compare patients in the pre-pandemic and pandemic cohorts. Results A total of 72,874 colorectal cases were included. There were 17.7% less cases in 2020. Rate of readmission was similar in both groups (9.6% vs. 9.4%). There were fewer patients discharged to a facility such as nursing facility or rehabilitation center in 2020, with more patients discharged home. Year was not associated with readmission on multivariable analysis. In the matched cohort, readmission rates did not differ (9.7% vs. 9.3% p  = 0.129) nor did mortality (0.8% vs. 0.8% p  = 0.686). Conclusions No difference in readmission rates before or during the COVID-19 pandemic was observed; suggesting increased pressure to keep patients out of hospital in the COVID-19 pandemic did not result in patients being rushed home requiring repeat admission. More patients were discharged home with fewer to rehabilitation or nursing facilities in 2020, suggesting success with avoiding transitional services in the right setting.

Background: Laparoscopic pancreaticoduodenectomy (PD) is an emerging surgical technique in Canada. Perioperative outcomes associated with initial Canadian institutional experience with this technique have not been described. This study describes our institutional experience and compares perioperative outcomes of laparoscopic PD to National Surgical Quality Improvement Program (NSQIP)-reported open PD cases using a propensity-score-matched (PSM) analysis. Methods: Institutional data were collected prospectively from sequential laparoscopic PD patients between 2019 and 2022. PSM was performed using the subset of patients undergoing open PD identified in the 2020 NSQIP procedure targeted Participant Use Data File (PUF) for pancreatectomy, which was merged with the 2020 main NSQIP PUF to include perioperative outcomes. Institutional and NSQIP data were matched on age, sex, body mass index, comorbidities, pathology, pancreatic duct diameter and gland texture. Results: Sixty laparoscopic PD were performed at our institution from 2019 to 2020; 33% (n = 20) were converted to open. On PSM analysis, there was no significant difference between laparoscopic and open PD for length of stay (11.4 d v. 8.5 d, 95% confidence interval [CI] -0.49 to -6.38, p = 0.09), postoperative pancreatic fistula (39.6% v. 22.6%, 95% CI -0.94 to 34.8, p = 0.063), delayed gastric emptying (9.4% v. 15.1, 95% CI -18.9 to 7.6, p = 0.4), superficial surgical site infections (SSIs) (11.3% v. 5.6%, 95% CI -5.3 to 16.6, p = 0.31), deep SSIs (18.7% v. 15.1%, 95% CI -10 to 17.6, p = 0.59), 30-day readmission (24.5% v. 18.9%, 95% CI -9.5 to 20.8, p = 0.47), or 30-day mortality (3.8% v. 3.8%). Laparoscopic PD was associated with higher 30-day reoperation rate (13.2% v. 1.9%, 95% CI 1.3 to 21.3, p = 0.03). Conclusion: Laparoscopic PD remains in the early stage of the learning curve. Despite equivalence to open PD in the majority of outcomes, improvement must be made in reoperation rates. Ongoing analysis is needed to elucidate whether outcomes become superior as the technique refines over time.

Differences in outcomes between males and females with biliary tract cancer (BTC) has been previously reported but not studied. This was a population-based retrospective cohort study of patients undergoing BTC resection in Ontario between 2002 and 2012. Descriptive statistics on patient, disease, and treatment-related factors in each BTC subtype were reported. Kaplan Meier Curves and Cox Proportional Hazards analysis were used to examine the univariate relationship between sex and overall survival. 714 patients underwent resection of a BTC. Kaplan Meier Curves shows trends towards different survival for males and females in different BTC subtypes: improved for females with intrahepatic and ampullary cancers and poorer survival for females with perhilar and distal cholangiocarcinomas. These trends were not statistically significant. Sex may be an important factor in overall survival following resection of BTC. Further work is needed to better characterize the relationship between sex and outcomes of BTC. •Biliary tract cancer (BTC) subtypes represent individual disease processes and should be studied separately.•This study describes sex-related survival differences between BTC subtypes. These trends, however, did not reach statistical significance.•Collaborative work is required to establish larger cohorts to characterize the relationship between sex and outcomes in BTC.

Background Arterial lactate is frequently monitored to indicate tissue hypoxia and direct therapy. We sought to determine whether early post-hepatectomy lactate (PHL) is associated with adverse outcomes and define factors associated with PHL. Methods Hepatectomy patients at a single institution from 2003 to 2012 with PHL available were included. Univariable and multivariable analyses examined factors associated with PHL and the relationship between PHL and 30-day major morbidity (Clavien grade III–V), 90-day mortality, and length of stay (LOS). Results Of 749 hepatectomies, 490 were included of whom 71.4% had elevated PHL (≥2 mmol/L). Cirrhosis (coefficient 0.31, p  = 0.039), Charlson comorbidity index (coefficient 0.05, p  < 0.001), major resections (coefficient 0.34, p  < 0.001), procedure time (coefficient 0.08, p  < 0.001), and blood loss (coefficient 0.11, p  < 0.001) were associated with PHL. As lactate increased from <2 to ≥6 mmol/L, morbidity rose from 11.6 to 40.6%, and mortality from 0.7 to 22.7%. PHL was independently associated with 90-day mortality (OR 1.52 p  < 0.001) and 30-day morbidity (OR 1.19, p  = 0.002), but not LOS (rate ratio 1.03, p  = 0.071). Conclusion Patients with elevated PHL in the initial postoperative period should be carefully monitored due to increased risk of major morbidity and mortality. Further research on the impact of lactate-directed fluid therapy is warranted.

Background Guidelines recommend 28 days venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) following major abdominal surgery for cancer. Overall adherence with these recommendations is poor, but little is known about feasibility and tolerability from a patient perspective. Methods An institution-wide policy for routine administration of 28 days of post-operative LMWH following major hepatic or pancreatic resection for cancer was implemented in April 2013. Patients having surgery from July 2013 to June 2015 were approached to participate in an interview examining adherence and experience with extended duration LMWH. Results There were 100 patients included, with 81.4 % reporting perfect adherence with the regimen. The most frequent reasons for non-adherence were that a healthcare provider stopped the regimen or because of poor experience with injections. Most patients were able to correctly recall the reason for being prescribed LMWH (82.6 %), and 78.4 % of patients performed all injections themselves. Over half the patients (55.7 %) did not find the injections bothersome. Conclusion Patients reported high adherence and a manageable experience with post-operative extended-duration LMWH in an ambulatory setting following liver or pancreas resection. These findings suggest that patient adherence is not a major contributor to poor compliance with VTE prophylaxis guidelines.

Abstract Background Optimal colonoscopy training curricula should minimize stress and cognitive load. This study aimed to determine whether withdrawal or insertion colonoscopy skills training is associated with less stress or cognitive load for trainees or trainers. Methods In Phase I, participants were randomized to train on either insertion or withdrawal in a simulated environment. In Phase II, participants were randomized to begin with either insertion or withdrawal in patient encounters. Salivary cortisol levels, heart rate, and State-Trait Anxiety Inventory (STAI) surveys were used to assess stress in trainees and trainers. NASA Task Load Index (TLX) survey was used to assess cognitive workload in trainees. Results In Phase I, trainee stress increased during the simulation training during both withdrawal and insertion compared to baseline, while trainer stress changed minimally. Cognitive load was higher for trainees during withdrawal (P = 0.005). In Phase II, trainers’ STAI scores were greater during insertion training (P = 0.013). Trainees’ stress was highest prior to beginning patient training and decreased during training, while trainer’s stress increased during training. Trainees reported insertion training being of greater value (70.0%), while trainers reported withdrawal was preferred (77.8%). Conclusion Trainees and trainers exhibit important differences in stress during colonoscopy skills training. Trainees reported more stress during simulation training and greatest cognitive load during simulation withdrawal, whereas trainers reported greatest stress during patient encounters, particularly training of insertion techniques. Attention to the effect of stress on trainees and trainers and the drivers of stress is warranted and could be incorporated in competency based medical education.