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Background Severe complicated intra-abdominal sepsis (SCIAS) has high mortality, thought due in part to progressive bio-mediator generation, systemic inflammation, and multiple organ failure. Treatment includes early antibiotics and operative source control. At surgery, open abdomen management with negative-peritoneal-pressure therapy (NPPT) has been hypothesized to mitigate MOF and death, although clinical equipoise for this operative approach exists. The Closed or Open after Laparotomy (COOL) study ( https://clinicaltrials.gov/ct2/show/NCT03163095 ) will prospectively randomize eligible patients intra-operatively to formal abdominal closure or OA with NPTT. We review the ethical basis for conducting research in SCIAS. Main body Research in critically ill incapacitated patients is important to advance care. Conducting research among SCIAS is complicated due to the severity of illness including delirium, need for emergent interventions, diagnostic criteria confirmed only at laparotomy, and obtundation from anaesthesia. In other circumstances involving critically ill patients, clinical experts have worked closely with ethicists to apply principles that balance the rights of patients whilst simultaneously permitting inclusion in research. In Canada, the Tri-Council Policy Statement-2 (TCPS-2) describes six criteria that permit study enrollment and randomization in such situations: (a) serious threat to the prospective participant requires immediate intervention; (b) either no standard efficacious care exists or the research offers realistic possibility of direct benefit; (c) risks are not greater than that involved in standard care or are clearly justified by prospect for direct benefits; (d) prospective participant is unconscious or lacks capacity to understand the complexities of the research; (e) third-party authorization cannot be secured in sufficient time; and (f) no relevant prior directives are known to exist that preclude participation. TCPS-2 criteria are in principle not dissimilar to other (inter)national criteria. The COOL study will use waiver of consent to initiate enrollment and randomization, followed by surrogate or proxy consent, and finally delayed informed consent in subjects that survive and regain capacity. Conclusions A delayed consent mechanism is a practical and ethical solution to challenges in research in SCIAS. The ultimate goal of consent is to balance respect for patient participants and to permit participation in new trials with a reasonable opportunity for improved outcome and minimal risk of harm.

In single-stage hernia repair in the setting of contaminated fields there is a high rate of infection following mesh repair. New strategies to decrease infection in this challenging patient population are needed. Stimulan calcium sulfate antibiotic beads (CSAB) are a biodegradable material that deliver high concentrations of antibiotics locally to a site of insertion. Their use in the prevention of infection has not been described in hernia graft implantation. Here we describe our use of CSAB in a series of 11 patients with modified Ventral Hernia Working Group class III and Centers for Disease Control and Prevention class II–IV wounds undergoing single-stage incisional ventral hernia repair. We found that implantation of CSAB in single-stage hernia repair in the setting of contaminated fields was feasible with low systemic antibiotic levels. Further research should be undertaken to investigate the efficacy of this novel tool in hernia repair.

The original article [1] contained a typo in author, Federico Coccolini’s name. This has now been corrected.

This study tested the effectiveness and perceived value of a palliative/end-of-life (P/EOL) curriculum for junior residents implemented during an intensive care unit (ICU) rotation. Residents rotating through the ICU over a 6-month period completed pre- and post-curriculum surveys evaluating their self-assessed efficacy in providing P/EOL care and attitudes towards P/EOL care. Scores were analyzed using a paired Student t test. Seventeen of 19 (90%) residents completed both the pre- and post-curriculum evaluations. The P/EOL curriculum increased self-assessed efficacy ratings in the domains of pain management ( P = .04), psychosocial knowledge ( P = .001), communicator knowledge ( P = .001), professional knowledge ( P = .002), and manager knowledge ( P < .001). The rotation was rated as being valuable in preparing residents to care for patients near the end-of-life ( P < .05), with surgery residents indicating it to be the most valuable rotation in their training program for learning about P/EOL care. An ICU P/EOL curriculum improves self-assessed efficacy scores across multiple domains in P/EOL care and is seen as a valuable educational experience.

Few studies have addressed the quality of dictated operative reports (ORs). This study documents changes in resident dictation after the introduction of a standardized OR template. Twenty residents dictated an OR based on a surgical procedure video. Residents were randomized to receive an OR template or no intervention. Residents dictated another report 3 months later. Outcomes measures were dictation quality using a previously validated tool and resident comfort with dictation. There was no overall difference in quality in the intervention group as measured by the Structured Assessment Form (SAF) (28.6 vs 30.0, P = .36) and Global Quality Ratings Scale (GQRS) (21.7 vs 21.8, P = .96). However, junior resident subgroup analysis revealed an improvement in the intervention group on both the SAF (23.2 vs 28.3, P = .02) and GQRS (17.1 vs 20.4, P = .02). Subjective comfort level improved in the intervention group ( P = .02). The operative dictation template can significantly improve resident comfort level with dictation and has the potential to improve the quality of junior resident dictations.

Background: Competency-based medical education is a framework of organized representations of sets of interrelated knowledge and procedural skills. Each competency is aligned with entrustable professional activities (EPAs). These are specified by regulatory bodies. Undergraduate medical education knowledge and their associated EPAs are designed to prepare learners for the first year of their residencies. Methods: This oral presentation will provide an overview of a project that used a virtual patient case (VP) to highlight and address specific postgraduate medical education EPAs. Supported by the Canadian Association of General Surgeons, a VP was developed by a clinical content expert and then integrated into a virtual patient case application by developers with strong pedagogical and clinical backgrounds. The clinical narrative was initially constructed using a template that was then followed by online discussions, reviews and modifications. The completed case will be peer-reviewed prior to publication. Results: The resulting case provides an online standardized exercise for learners that can be made available irrespective of geographical limitations. This process permits wide distribution of clinical content expertise. The addition of individualized metrics and data allows for objective assessment of competencies and EPAs and permits formative identification of strengths and weaknesses that can then be addressed. The authors will present examples of several Canadian EPAs as well as associated CanMEDS roles that can be related to specific elements of the case. Conclusion: VPs aligned with EPAs provide an innovative teaching strategy for on-site and remote learning. They permit self, formative and summative assessment and provide educators with innovative evaluation methodologies.

Over the past 5 years, there has been a groundswell of support in Canada for the development of organized, focused and multidisciplinary approaches to caring for acutely ill general surgical patients. Newly forged acute care surgery (ACS) services are beginning to provide prompt, evidence-based and goal-directed care to acutely ill general surgical patients who often present with a diverse range of complex pathologies and little or no pre- or postoperative planning. Through a team-based structure with attention to processes of care and information sharing, ACS services are well positioned to improve outcomes, while finding and developing efficiencies and reducing costs of surgical and emergency health care delivery. The ACS model also offers enhanced opportunities for surgical education for students, residents and practicing surgeons, and it will provide avenues to strengthen clinical and academic bonds between the community and academic surgical centres. In the near future, cooperation of ACS services from community and academic hospitals across the country will lead to the formation of systems of acute surgical care whose development will be informed by rigorous data collection and research and evidence-based quality-improvement initiatives. In an era of increasing subspecialization, ACS is a strong unifying force in general surgery and a platform for collective advocacy for an important patient population.

Background: Emergency general surgery (EGS) represents a significant proportion of general surgical care provided in Canada. However, a comprehensive understanding of the national burden of EGS is lacking. The aim of this study was to describe the volume of EGS care in Canadian hospitals, as well as provincial variation in epidemiology and outcomes. Methods: This population-based cohort study used data obtained from the Canadian Institute for Health Information (CIHI) to identify adult patients admitted to hospital emergently for GS diagnoses from 2015 to 2020 in all provinces and territories except Quebec. Diagnoses were identified from a predefined list of International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada codes, and were classified as hepatopancreaticobiliary (HPB), upper gastrointestinal (UGI), colorectal, hernia, skin/soft tissue, vascular, general abdominal, and other. Data were obtained on demographics, procedures, comorbidities, complications and mortality. Average annual incidence rate for all conditions was calculated and compared among provinces/territories. Descriptive analyses were completed. Results: From 2015 to 2020, there were 1 199 045 patients identified, the majority of whom (64%) were treated in community-based centres. The average annual incidence rate was 873 cases per 100 000, representing approximately 11% of all annual hospital admissions across the country. Variability was seen among provinces (range 809-1216/100 000). The most common diagnoses in the cohort were HPB conditions (26%), followed by UGI (24%), and colorectal (15%). There was less regional variation, with HPB conditions predominating across all jurisdictions except all 3 territories where UGI was most common. Overall mortality for the study period was 2.4%, with variation among provinces (range 0.8%-3.1%). Major complications occurred in 3.2% of patients, again with significant provincial variation (range 1.6%-4.6%). Conclusion: The burden of EGS disease in Canada is substantial. Heterogeneity in disease presentation, severity and patient outcomes requires a systems approach to identify the ideal structural factors, processes of care, and patient partnerships to optimize outcomes for this diverse population.