Surgery training programs in Canada and the United States have recognized the need to modify current models of training and education. The shifting demographic of surgery trainees, lifestyle issues and an increased trend toward subspecialization are the major influences. To guide these important educational initiatives, a contemporary profile of Canadian general surgery residents and their impressions of training in Canada is required.
We developed and distributed a questionnaire to residents in each Canadian general surgery training program, and residents responded during dedicated teaching time.
In all, 186 surveys were returned for analysis (62% response rate). The average age of Canadian general surgery residents is 30 years, 38% are women, 41% are married, 18% have dependants younger than 18 years and 41% plan to add to or start a family during residency. Most (87%) residents plan to pursue postgraduate education. On completion of training, 74% of residents plan to stay in Canada and 49% want to practice in an academic setting. Almost half (42%) of residents identify a poor balance between work and personal life during residency. Forty-seven percent of respondents have appropriate access to mentorship, whereas 37% describe suitable access to career guidance and 40% identify the availability of appropriate social supports. Just over half (54%) believe the stress level during residency is manageable.
This survey provides a profile of contemporary Canadian general surgery residents. Important challenges within the residency system are identified. Program directors and chairs of surgery are encouraged to recognize these challenges and intervene where appropriate.
Centre for the Advancement of Minimally Invasive Surgery, Room No. 502 CSC, 10240 Kingsway Avenue, Royal Alexandra Hospital, Edmonton, Alberta T5H 3V9, Canada; University of Alberta, 2-590 Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta T6G 1C9, Canada.
Am J Surg. 2014 May;207(5):743-6; discussion 746-7
Medical tourists are defined as individuals who intentionally travel from their home province/country to receive medical care. Minimal literature exists on the cost of postoperative care and complications for medical tourists. The costs associated with these patients were reviewed.
Between February 2009 and June 2013, 62 patients were determined to be medical tourists. Patients were included if their initial surgery was performed between January 2003 and June 2013. A chart review was performed to identify intervention costs sustained upon their return.
Conservatively, the costs of length of stay (n = 657, $1,433,673.00), operative procedures (n = 110, $148,924.30), investigations (n = 700, $214,499.06), blood work (n = 357, $19,656.90), and health professionals' time (n = 76, $17,414.87) were summated to the total cost of $1.8 million CAD.
The absolute denominator of patients who go abroad for bariatric surgery is unknown. Despite this, a substantial cost is incurred because of medical tourism. Future investigations will analyze the cost effectiveness of bariatric surgery conducted abroad compared with local treatment.
Advanced laparoscopic courses serve as a comprehensive and popular Continuing Medical Education (CME) activity. Knowledge of basic laparoscopy is an assumed prerequisite for attendance at these courses.
To determine the baseline laparoscopic knowledge of attendees at an advanced laparoscopic surgical course.
A.17-question examination was designed using data from the basic laparoscopic quizzes on the Society of American Gastrointestinal Surgeons (SAGES) website (http://www.sages.org/education/quiz). The questions covered 4 realms of basic laparoscopy: access, pneumoperitoneum, camera navigation, and surgical instrumentation. The questionnaire was distributed to all attendees at an advanced laparoscopic course at the 2009 Canadian Surgical Forum organized by the Canadian Association of General Surgeons.
Forty-three respondents completed the survey. Fifty-three percent (53%) of responders had been in practice for more than 10 years and 65% had over 5 years experience. Fifty-five percent (55%) [24/43] of respondents listed laparoscopic courses as the sole means of laparoscopic training. Sixty-one percent (61%) [28/43] were performing > 50 laparoscopic cases per year. The median score on the knowledge-based questions was 70.6% [12/17]. In terms of overall score, respondents with more than 5 years experience performed similarly to respondents with less than 5 years experience (73% correct answers). Interestingly, in a subgroup analysis, respondents performed well in camera skills and pneumoperitoneum-themed questions (84% correct answers) but performed poorly on questions pertaining to instrumentation or access (52% correct answers).
Basic laparoscopic knowledge among the attendees of an advanced laparoscopic course is suboptimal. A review of basic principles of laparoscopy particularly pertaining to instrumentation and access should form part of these CME activities.
This study investigates the feasibility of performing advanced minimally invasive surgery (MIS) in a nonspecialized practice environment.
We conducted a cross-sectional survey of all community general surgeons currently practising in Ontario.
Few community surgeons perform a high volume (> 10 procedures per yr) of advanced MIS. Most (70%) believe it is important to acquire additional skills in advanced MIS. The most appropriate methods for learning advanced MIS are believed to be expert mentoring (79.7%), courses (77.2%) and a colleague mentor (63.9%). A total of 57.6% of respondents have attended a course in MIS while in practice, and most have access to a reasonable variety of instrumentation. Respondents believe that 57.6% of assistants, 54.8% of nurses and 43.4% of anaesthetists are relatively inexperienced with advanced MIS. Barriers to establishing advanced MIS include limited operating room access (50%), resources or equipment (45.2%) and limited expert mentoring (43.6%). Surgeons with less than 10 years of practice found lack of trained nursing staff (7.9% v. 4.2%, p = 0.01) and experienced assistants (12% v. 6.2%, p = 0.008) to be more important barriers than did those with over 10 years of practice, respectively.
Most general surgeons working in Ontario are self-taught with respect to MIS skills, and few perform a high volume of advanced MIS. Only one-half of all respondents have access to skilled MIS operating room nurses, surgical assistants or anesthesiology. Despite this, general surgeons perceive the greatest barriers to introducing advanced MIS procedures to be limited access to operating rooms, resources or equipment and limited mentoring. This study has shown that the role of the surgical team in advanced MIS may be underestimated by many general surgeons. These data have important implications in training general surgeons and in incorporating additional advanced MIS procedures into the armamentarium of general surgeons.
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Protracted, multi-year wait times exist for bariatric care in Canada. Our objective was to examine wait-listed patients' health status and perceptions regarding the consequences of prolonged wait times using a cross-sectional study design nested within a prospective cohort.
150 consecutive consenting subjects wait-listed for multi-disciplinary bariatric assessment in a population-based medical/surgical bariatric program were surveyed. Health status was measured using a visual analogue scale (VAS). A Waiting List Impact Questionnaire (WLIQ) examined employment, physical stress, social support, frustration, quality of life, and satisfaction with care. Multivariable linear regression analysis adjusted for age, sex and BMI identified independent predictors of lower VAS scores.
136 (91%) subjects were women, mean age was 43?years (SD 9), mean BMI was 49.4 (SD 8.3) kg/m2 and average time wait-listed was 64?days (SD 76). The mean VAS score was 53/100 (SD 22). According to the WLIQ, 47% of subjects agreed/strongly agreed that waiting affected their quality of life, 65% described wait times as 'concerning' and 81% as 'frustrating'. 86% reported worsening of physical symptoms over time. Nevertheless, only 31% were dissatisfied/very dissatisfied with their overall medical care. Independent predictors of lower VAS scores were higher BMI (beta coefficient 0.42; p?=?0.03), unemployment (13.7; p?=?0.01) and depression (10.3; p?=?0.003).
Patients wait-listed for bariatric care self-reported very impaired health status and other adverse consequences, attributing these to protracted waits. These data may help benchmark the level of health impairment in this population, understand the physical and mental toll of waiting, and assist with wait list management.
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Within the last decade, several authors have proposed laparoscopic sleeve gastrectomy (LSG) as a potential definitive treatment for morbid obesity. While initially perceived as being a solely restrictive procedure, it is now theorized to have additional hormonal effects (primarily the reduction of circulating levels of plasma ghrelin). However, there is limited supporting evidence for this claim. Therefore, the purpose of our study is to conduct a systematic review of the literature to clarify the effects of LSG on modulation of postoperative ghrelin concentrations. A comprehensive literature search for published or unpublished studies of sleeve gastrectomy (SG) and ghrelin written in English prior to February 2013 was performed using Pubmed, EMBASE, the Cochrane database, and Scopus. Gray literature was also searched through Google. Inclusion criteria for searches were: randomized controlled trials, non-randomized clinical trials, retrospective and prospective cohort studies, or case series. Seven studies were deemed suitable for analysis. The mean patient age was 43?±?8.8 years and female percentage was 74.4?±?15.3 %. The mean initial BMI was 46.2?±?7.8 and mean follow-up time was 9.5?±?15 months. The mean postoperative BMI was 37.3?±?5.8 over the same follow-up period. Pooled mean preoperative ghrelin levels were 698.4?±?312.4 pg/ml and postoperative levels were 414.1?±?226.3 pg/ml (P?
Bariatric surgery is typically offered in larger health care centers, forcing patients to travel long distances to access care. An adult obesity program was established in Whitehorse, Yukon based on the multidisciplinary adult bariatric clinic in Edmonton, to alleviate long-distance care difficulties. This study analyzes patient/health care staff satisfaction and surgical outcomes for this program.
A survey was administered to patients and health care staff at Edmonton and Whitehorse. Patient charts were reviewed. A multivariate linear regression predicted the main effect of travel distance and other clinical covariates on follow-up compliance.
Postoperative body mass index, complications, and satisfaction scores were similar. Whitehorse patients had higher rates of follow-up (85.6% vs 71.1%, P = .002).
The Whitehorse Bariatric Program provides perioperative obesity care comparable to a larger center. Patient follow-up and satisfaction suggest a highly successful program. This may serve as a model for improving access to obesity services across Canada.
Obesity rates have reached epidemic levels with over 300 million obese individuals worldwide. Laparoscopic sleeve gastrectomy (LSG) as a primarily restrictive bariatric surgical procedure has been shown to be effective in producing marked weight loss. However, LSG-associated gastric leakage and hemorrhages remain the most important challenges postoperatively. Staple line buttress reinforcement has been suggested to reduce these postoperative complications. Our objective was to assess staple line buttress reinforcement via the Duet™ tissue reinforcement stapler system in morbidly obese patients undergoing LSG as part of a comprehensive weight management strategy, focusing on postoperative complications.
Between January 2008 and April 2011, we retrospectively reviewed the medical records of 116 consecutive patients that underwent LSG with staple line buttress reinforcement at an academic teaching hospital with advanced bariatric fellowship.
The mean age of patients was 44.3?±?9.5 years, with mean preoperative BMI of 44?±?7 kg/m2. The mean operative time to perform LSG was 96?±?25 min. Postoperative weight was significantly lower following LSG at 1-year follow-up compared to baseline (104?±?25 vs. 125?±?27 kg, P?
Obesity has become a major health concern in Canada. This has resulted in a steady rise in the number of bariatric surgical procedures being performed nationwide. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is not only the most common bariatric procedure, but also the gold standard to which all others are compared. With this in mind, it is imperative that all gastrointestinal surgeons understand the LRYGB and have a working knowledge of the common postoperative complications and their management. Early postoperative complications following LRYGB that demand immediate recognition include anastomotic or staple line leak, postoperative hemorrhage, bowel obstruction and incorrect Roux limb reconstructions. Later complications may be challenging to differentiate from other gastrointestinal disorders and include anastomotic stricture, marginal ulceration, fistula formation, weight gain and nutritional deficiencies. We discuss the principles involved in the management of each complication and the timing of referral to specialist bariatric centres.
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The number of Canadians who self-refer for bariatric surgery outside of Canada or to private clinics within Canada remains undefined. The outcomes from this questionable practice have not been evaluated systematically to date.
We completed a chart review of known cases referred to our center for complications related to medical tourism and bariatric surgery.
We present a series of patients who have experienced complications because of medical tourism for bariatric surgery and required urgent surgical management at a tertiary care center within Canada. Complications have resulted from 3 commonly used procedures: adjustable gastric banding, gastric sleeve resection, and Roux-en-Y gastric bypass.
Because of this review, we propose that a medical tourism approach to the surgical management of obesity-a chronic disease-is inappropriate and raises clear ethical and moral issues.