RRD

RESIDENTS’ RESEARCH DAY

May 17, 2018 | Paetzold Health Education Centre | VGH

Residents’ Research Day | May 17, 2018 VISITING PROFESSOR

Dr. Paola Fata

Assistant Dean, Resident Professional Affairs
President-Elect, Canadian Association of General Surgeons (CAGS)

Associate Professor of Surgery, McGill University

P a g e |1

Residents’ Research Day | May 17, 2018 P a g e |2

General Surgery Residency Program

RESIDENTS’ RESEARCH DAY

May 17, 2018 | Paetzold Health Education Centre | VGH

VISITING PROFESSOR
Paola Fata, MD CM, FRCSC

Assistant Dean
Resident Professional Affairs
President-Elect
Canadian Association of General Surgeons (CAGS)
Associate Professor of Surgery
McGill University

Dr. Paola Fata serves as Assistant Dean, Resident Affairs, and is President-Elect of the Canadian Association of General
Surgeons (CAGS). A graduate of McGill’s Faculty of Medicine, Dr. Fata completed her postgraduate surgical training at
McGill and at the University of Manitoba before completing a trauma fellowship at the Inova Fairfax Regional Trauma
Center in Virginia. An Associate Professor of Surgery at McGill University, Dr. Fata has been Program Director of the
General Surgery Residency Program for the past 10 years until she accepted her position as Assistant Dean in 2017.
Over the course of her career, Dr. Fata has been nominated for, and received, numerous awards, including multiple
Teaching Excellence Awards within the Department of Surgery. In 2012, she was named to the Faculty Honour List for
Educational Excellence at McGill University. She has served on numerous national committees, as a member of the Royal
College Specialty Committee in General Surgery, as Vice-Chair of the Area of Focused Competence in Trauma and is a
previous member of the Royal College Test Committee in General Surgery.
Currently, she is Co-Chair for the Canadian Association of General Surgeons Exam Committee and Chair of the General
Surgery Educational Leadership Council. She has served on a number of steering committees at the Royal
College including work hours, task force planning and the Advisory committee for surgical foundations. Dr. Fata’s
research interest is focused on investigating quality improvement in residency training and education as well as trauma.

Residents’ Research Day | May 17, 2018 P a g e |3

JUDGES

Morad Hameed, MD MPH FRCSC FACS

Associate Professor and Chief, Divisions of General Surgery,
Vancouver Acute and University of British Columbia

Morad Hameed is a trauma surgeon and intensivist at the Vancouver General Hospital (VGH) and an Associate Professor of
Surgery at the University of British Columbia (UBC). He completed medical school and surgical residency at the University
of Alberta, graduate studies in public health at Harvard University, and fellowships in Trauma Surgery and Surgical Critical
Care at the University of Miami. He was an Assistant Professor of Surgery at the University of Calgary before moving to
Vancouver. He currently serves as the Chief of the Divisions of General Surgery, Vancouver Acute and University of British
Columbia. He is a past President of the Canadian Association of General Surgeons. His clinical and research interests are in
trauma and acute care surgery, with a focus on trauma systems, social determinants of health, and health information
technology.

David E. Konkin, MD FRCSC FACS

Clinical Assistant Professor, UBC
Head of Department of Surgery (Local), Eagle Ridge Hospital
Regional Head of Division of General Surgery, Fraser Health Authority
Local Head of Division of General Surgery, Royal Columbian Hospital/Eagle Ridge Hospital

Dr. Konkin was born and raised in British Columbia. He graduated medical school and completed his specialty training at
the University of British Columbia. He took a special interested in advanced laparoscopic surgery as well as complex
abdominal wall reconstruction. In 2007 he joined the staff of the Royal Columbian Hospital in New Westminster and Eagle
Ridge Hospital in Port Moody.
Affiliated with the University of British Columbia, today he holds a position of Clinical Assistant Professor in surgery. He
also holds the position of Regional Division Head of General Surgery for the Fraser Health Authority.
Dr. Konkin performs various types of major abdominal operations including gastrointestinal, colorectal, gallbladder,
trauma and hernia surgery. Over his career he has developed a strong interest in improving the rehabilitation of people
with abdominal hernias. He has enthusiastically supported the use of local anesthesia and sedation for hernias. He has also
embraced the use of laparoscopic repair of inguinal hernias. Today, he has a busy surgical practice, which he performs
at Eagle Ridge Hospital in Port Moody and Royal Columbian Hospital in New Westminster. He also has privileges at
the New Westminster Surgical Centre in New Westminster. He is a consulting general surgeon for WorkSafeBC Visiting
Specialist Clinic and the BC Lions.

Residents’ Research Day | May 17, 2018 P a g e |4

2017 RESIDENTS’ RESEARCH DAY WINNERS

Congratulations to last year’s winners!

Best Research Presentations

Dr. Kristin DeGirolamo Structure, Process and Outcome in Acute Care Surgery

Dr. Dean Percy Saving the Axilla: Can We Reduce up Front Axillary Lymph Node Dissection in T1/T2
Best Research Proposal Breast Cancers?

Dr. Katrina Duncan Usability of a Mobile Electronic Platform for Trauma Patient Resuscitation and
Management

This event is an Accredited Group Learning Activity eligible for up to 6.0 Section 1 credits as defined by the
Maintenance of Certification program of the Royal College of Physicians and Surgeons of Canada. This program
has been reviewed and approved by UBC Division of Continuing Professional Development. Each physician should
claim only those credits he/she actually spent in the activity.

Residents’ Research Day | May 17, 2018 P a g e |5

MORNING SESSION
Moderator | Dr. Adam Meneghetti

0730-0800 BREAKFAST AND Welcome and Introduction of Visiting Professor & Judges
0800-0810 REGISTRATION
Dr. Adam Meneghetti

Research Presentations – Podium

8:15-8:30 Dr. Nicole Jedrzejko Global Surgery Initiative Sustainability Systematic Review Page
8:30-8:45 Dr. Nicole Mak Preoperative Evaluation of Frailty in the Older Surgical Patient 8
8:45-9:00 Dr. Anu Ghuman Surgical Site Infection in Elective Colon & Rectal Resections: Effect 9
of Oral Antibiotics
9:00-9:15 Dr. David Kim Time Driven Activity Based Costing for Acute Trauma Care 10-11
9:15-9:30 Dr. Michael Bleszynski
9:30-9:45 Dr. Caroline Huynh Open Abdomen in Liver Transplantation 12
13
Processes and Complications in Emergency General Surgery 14

9:45-10:00 Dr. Joseph Margolick Limited Usefulness of the NSQIP Surgical Risk Calculator in 15
Stratifying Operative Risk in Patients Undergoing Head and Neck
10:00-10:15 BREAK Surgery
10:15-10:30 Dr. Nicole Jedrzejko
Lead Level Monitoring Retained Missiles Algorithm 16
10:30-10:45 Dr. Nicole Mak 17
Are Resident Physicians Safe Drivers after Extended-Duration Work 18
10:45-11:00 Dr. Dean Percy Shifts? 19
11:00-11:15 Dr. Sadiq Al Khaboori Mental Toughness in Surgeons: Is There Room for Improvement?
Comparison of Early Post-Operative Outcomes Between 20
11:15-11:30 Dr. Annie Lalande Asymptomatic Fecal Immunochemical Test-Screened and 21
11:30-11:45 Dr. Quinn Gentles Symptomatic Patients Undergoing Surgery for Colorectal Cancer 22
11:45-12:00 Charlotte Laane The Establishment of a Trauma Registry in Gondar, Ethiopia
Transanal Endoscopic Microsurgery As Day Surgery
Social Determinants of the Need for Emergency Surgery in Patients
Presenting with an Inguinal Hernia

12:00-12:30 LUNCH

Residents’ Research Day | May 17, 2018 P a g e |6

AFTERNOON SESSION
Moderator |Dr. Tracy Scott

VISITING PROFESSOR LECTURE Mentorship and Transformational Leadership in Surgical Training 23
12:30-13:30 Dr. Paola Fata 24
13:30-13:45 Dr. Jon Ramkumar Safety and Outcomes of Repeat TEM
13:45-14:00 Dr. Hannah Adamson Intra-Operative Frozen Section Analysis of Margin Status as a 25
Quality Indicator in Gastric Cancer Surgery 26
14:00-14:15 Dr. Kristin DeGirolamo A Day in the Life of Acute Care Surgery in Canada 27
14:15-14:30 Dr. Jake Hiebert Dual-Energy Computed Tomography
14:30-14:45 Dr. Vivian Ma Treatment of Recurrent or Persistent Pneumothorax in Children 28
with Glue Pleurodesis 29
14:45-15:00 Dr. Graeme Hintz Sclerotherapy in the Treatment of Rectal Prolapse in Children 30
15:00-15:15 Dr. Daniel Lustig Is Microductectomy Still Necessary to Diagnose Breast Cancer?
15:15-15:30 Dr. Emily Mackay The Effect of Neoadjuvant Therapy on the Surgical Management of 31
Breast Cancer 32
15:30-15:45 Dr. Elizaveta Vasilyeva Microscopic Margins in Pancreas Adenocarcinoma
15:45-16:00 Dr. Kathleen Garber ROTEM-Guided Detection of Hypercoagulability in Patients with 33
Traumatic Brain Injury
16:00-16:10 Dr. Nicole Mak Morbidity and Functional Outcomes in Older Persons Undergoing
Major Abdominal Surgery

Residents’ Research Day | May 17, 2018 P a g e |7

ABSTRACTS

GLOBAL SURGERY INITIATIVE SUSTAINABILITY SYSTEMATIC REVIEW

Authors

Nicole Jedrzejko1; Joseph Margolick1; Jenny Hoang Nguyen2; Maylynn Ding3; Phyllis Kisa4; S. Morad Hameed1; Emilie Joos1

Background

Building surgical capacity through international partnerships is a popular focus in global health to address gaps in surgical
access between high-income and low/middle-income countries (LMICs). This is the first and only systematic review identifying
all publications on global surgery initiatives (GSIs) between US/Canada and LMICs published from 2000-2016.

Methods

Our objective is to quantify and descriptively analyze collaborations in global surgery and propose a model for sustainability
based on six pillars: multidisciplinary collaboration, bilateral authorship, effective training, community engagement,
sustainable funding, and outcomes reporting. This systematic review uses methodology established by Preferred Reporting
Items for Systematic Reviews and Meta-analysis (PRISMA-P). A total of 3580 abstracts were gathered through PubMed,
Embase, Medline, and African Journals Online, and independently reviewed by four authors.

Results

Only 128 studies (3.6%) met inclusion criteria describing GSIs in 50 countries on 5 continents with collaboration between ≥1
institution (e.g., government, civil society, NGO, academic) from LMIC(s) and ≥1 from USA/Canada. Excluded studies were
nonsurgical, unilateral, or military initiatives. Of 128 independent global surgery initiatives identified, 56% had bilateral
authorship, 72% provided LMIC surgical training, and only 41% explicitly stated funding sources. Whereas 65% GSIs provided
data collection, only 30% were involved in quality improvement and 53% reported outcomes.

Conclusions

We identified 128 publications describing North American and LMIC GSIs published from 2000-2016, with analysis ongoing. No
publication fulfilled all six proposed pillars of sustainability. We encourage global surgical partnerships to strengthen GSIs with
foundations of bilateral needs and idea exchange, defined and measurable objectives, training/capacity building, and
continuous evaluation of program outcomes.

Specialty: surgery
Topic: global health/surgical accessibility/sustainability
Stage: presented at UBC Resident Research Day 2017 by Margolick, CAGS Canadian Surgery Forum 2017 by Jedrzejko, UBC Chung Day 2017 by
Jedrzejko, upcoming presentation at Bethune Conference in Global Surgery 2018, manuscript preparation for submission spring/summer 2018

1Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
2Faculty of Medicine, University of Toronto, Toronto, ON, Canada
3Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
4Department of Surgery, Makerere University, Uganda

Residents’ Research Day | May 17, 2018 P a g e |8

PREOPERATIVE EVALUATION OF FRAILITY IN THE OLDER SURGICAL PATIENT

Authors

Mak, N., Brasher, P., Jones, G., McGregor, M.J., Mayson, K., Warnock, G.

Background

Frailty is a broadly defined as a state of reduced physiological reserve. It has been associated with increased risk for poor
surgical outcomes. Our study aim was to describe anesthetists’ and surgeons’ self-reported current practice and barriers to
the preoperative identification of frailty.

Methods

This is a cross-sectional survey conducted on a convenience sample of surgeons and anesthetists. Physicians affiliated with
Canadian university institutions who are currently in training or in practice were invited to complete an on-line survey.

Results

A total of 105 anesthesiologists and 135 surgeons responded to the survey invitation. Less than 5% of physicians “always”
performed a formal frailty assessment in patients over 65 while 60% of physicians either “rarely” or “never” did. However,
87% consider the frailty assessment to be “fairly” to “very important”. Given a patient deemed to be frail, the large majority of
surgeons and anesthetists currently consider a change in management, particularly in the elective surgery population. The
most common barriers to routine screening were physicians’ unfamiliarity with existing frailty tools, a lack of clarity on how to
intervene upon frailty preoperatively and the restraints of time.

Conclusions

This survey study found that although many Canadian physicians adapt surgical management plans in the context of perceived
frailty, these clinical decisions are not based on a formal assessment. This identifies an area of quality improvement for the
older surgical patient.

Residents’ Research Day | May 17, 2018 P a g e |9

SURGICAL SITE INFECTION IN ELECTIVE COLON & RECTAL RESECTIONS: EFFECT OF ORAL ANTIBIOTICS

Authors

Ghuman, A.1, Kasteel, N.2, Brown, C.J.3, Karimuddin, A.A.3, Raval, M.J.3, Phang, P.T.3

Background

Surgical site infection (SSI) is a significant complication of colorectal surgery and remains one of the highest amongst all
surgeries. Role of mechanical bowel preparation (MBP) with oral antibiotics has been shown to be effective, but is not yet a
standardized practice and varies based on surgeon preference. Here, we assess the effect of the addition of oral antibiotics
with MBP on SSI rates.

Methods

Retrospective cohort study of consecutive, elective colon and rectal resections at a single academic center, before (n=307) and
after (n=189) addition of oral antibiotics from September 1 2014 to September 30 2016. All patients followed our ERAS
protocol, which includes MBP, oral carbohydrate loading, warming blankets, IV antibiotics, subcutaneous heparin, hair clipping
and chlorhexidine skin prep. SSIs were assessed using CDC criteria. SSIs were compared before and after addition of oral
antibiotics using chi-squared analysis. A subgroup analysis was performed on colon and rectal resections independently.
Univariate analysis was performed on potential SSI risk factors, followed by a multivariate logistic regression analysis with
adjusted odds ratio (OR, 95% confidence interval).

Results

SSI rates from pre vs. post intervention were: overall 19.9% vs. 9.5%, p<0.05; superficial 9.8% vs. 3.7%, p<0.05; organ space
10.1% vs. 5.8%, p=0.06. Subgroup analysis on colon resections only SSI rates from pre vs. post intervention: overall 17.9% vs.
4.6%, p<0.05; superficial 12.0% vs. 3.8%, p<0.05; organ space 6.0% vs. 0.9%, p<0.05. SSI rates for rectal resections pre vs. post
intervention: overall 22.8% vs. 16.3%, p=0.26; superficial 6.5% vs. 3.8%, p=0.36, organ space 16.3% vs. 12.5%, p=0.41.
Univariate analysis was performed on the colon resections and yielded significant effects for age (0.97, 0.95-2.00), open vs.
MIS (6.35, 2.57-15.67), MIS converted to open vs. MIS (4.57, 1.78-11.75), BMI (1.07, 1.02-1.13), wound protector (0.37, 0.18-
0.75), oral antibiotics (0.22, 0.08-0.58) and surgery date (0.94, 0.89-0.98), but not for sex, lesion location, OR duration, stoma,
wound class, ASA score, smoking, diabetes, steroid use, negative pressure wound dressings or surgeon. On multivariate
analysis, open vs. MIS (p=0.01), MIS converted to open (p=0.005) and oral antibiotics (p=0.02) remained as significant SSI
factors.

Discussion

Significant reduction in SSI was found after adding oral antibiotics to MBP. Subgroup analysis revealed significant reduction in
superficial and organ space SSIs for colon resections, but not for rectal resections. Operative technique (MIS vs. open and MIS
converted open) also had a significant effect on SSI. Small post-intervention number limits assessment of wound protectors
and negative pressure wound dressings. Further investigation is needed to understand isolated effects of oral antibiotics.

Table 1: SSI Results
COLON & RECTAL RESECTIONS:

Overall, n (%) MBP alone (n=307) MBP + Oral Abx (n=189) p value
Superficial, n (%) 61 (19.87) 18 (9.52) 0.002
30 (9.77) 7 (3.70) 0.008
0 (0.00) --
Deep, n (%) 0 (0.00) 11 (5.82) 0.06
Organ Space, n (%) 31 (10.10)
MBP + Oral Abx (n=109) p value
COLON RESECTIONS:

MBP alone (n=184)

Residents’ Research Day | May 17, 2018 P a g e | 10

Overall, n (%) 33 (17.93) 5 (4.59) 0.0004
Superficial, n (%) 22 (11.96) 4 (3.76) 0.01
Organ Space, n (%) 11 (5.98) 1 (0.92) 0.01
RECTAL RESECTIONS:
MBP alone (n=123) MBP + Oral Abx (n=80) p value
Overall, n (%) 28 (22.76) 13 (16.25) 0.26
Superficial, n (%) 8 (6.50) 3 (3.75) 0.36
Organ Space, n (%) 20 (16.26) 10 (12.50) 0.41

Table 2: Regression Results (colon only)
Potential Risk Factor Unadjusted OR [95% CI] p value Adjusted OR [95% CI] p value
0.03 0.98 [0.95, 1.01] 0.11
Age 0.97 [0.95, 1.00] 0.37
-- --
Sex 1.38 [0.69, 2.74] 0.54
0.51 -- --
Lesion Location
Left vs. Right 0.80 [0.39, 1.64] 0.01
Total vs. Right 1.49 [0.45, 4.89] 0.005

Operative technique <0.0001 5.32 [1.48, 19.04] --
Open vs. MIS 6.35 [2.57, 15.67] 0.07
MISOpen vs. MIS 4.57 [1.78, 11.75] 0.002 5.95 [1.70, 20.87]
--
OR Duration 1.00 [1.00, 1.01] 0.57 --
0.01 1.06 [1.00, 1.13] --
BMI 1.07 [1.02, 1.13] --
--
Stoma 2.79 [0.52, 14.92] 0.23 -- --
--
Wound Class 0.99 -- --
II vs. I --
II vs. III 1.32 [0.28, 6.21] 0.34 -- --
II vs. IV 2.44 [0.74, 8.00] 0.14 -- 0.76
0.02
ASA Score 1.57 [0.91, 2.69] 0.11 -- --
0.88
Smoking 0.69 [0.23, 2.08] 0.51 --
Diabetes 1.36 [0.52, 3.52] 0.53 --

Steroid Use 1.36 [0.29, 6.41] 0.70 --

NPWD 0.72 [0.21, 2.49] 0.60 --
0.007
Wound Protector 0.37 [0.18, 0.75] 1.18 [0.42, 3.34]
0.002
MBP + PO Abx 0.22 [0.08, 0.58] 0.15 [0.03, 0.77]

Surgeon 0.78 [0.57, 1.08] 0.14 --
0.009
Date of Surgery 0.94 [0.89, 0.98] 1.01 [0.92, 1.10]

“--" Denotes variables not included in the final regression model (p>0.05 on univariate screen)

1 General Surgery, University of British Columbia, Vancouver, BC, Canada P a g e | 11
2 General Surgery, University of Calgary, Calgary, AB, Canada
3 Colorectal Surgery, St. Paul’s Hospital, Vancouver, BC, Canada

Residents’ Research Day | May 17, 2018

TIME DRIVEN ACTIVITY BASED COSTING FOR ACUTE TRAUMA CARE

Authors

David Hyunjoong Kim BSc MD, Department of Surgery, University of British Columbia, Vancouver, BC, Andrew Nicol MBChB
PhD, Department of Surgery, University of Cape Town, Cape Town, South Africa, Larissa Roux MD MPH PhD SEM, Vancouver,
BC, Morad Hameed MD MPH FRCSCFACS, Department of Surgery, University of British Columbia, Vancouver, BC

Background

Trauma is a leading cause of morbidity and mortality globally, and places a heavy, and as yet largely unquantified, financial
burden on society. A micro-costing approach known as time dependent activity based costing (TDABC) has recently been
proposed as a means to measure the financial burden of trauma care. This study describes an early experience with a real
time approach to TDABC in a busy Level 1 trauma center.

Method

The Trauma Unit at Groote Schuur Hospital in Cape Town, South Africa uses an electronic clinical documentation interface
during assessment and resuscitation of trauma patients to create trauma care process maps. This electronic platform tracks
and time stamps all resuscitative assessments and interventions, linking them with costs derived from North American
actuarial and other established health care costing databases. A study investigator shadowed the trauma team for a 14-day
period, entering all aspects of trauma resuscitation into the platform in real time. Supply, equipment and space costs of
trauma were also identified by the GSH informatics department.

Results

A total of 96 patients were documented. Of these, 77 were males and 19 were females. Mean age was 39 years (range: 15 - 96
years). Their trauma mechanisms were road traffic (n=24), stab wound (n=21), gunshot wound (n=17), fall (n=14), community
assault (n=9), struck against or by object (n=5), or struck against or by person (n=3). Process maps were developed for each
patient and showed an average resuscitation time of 15 hours. Average resuscitation cost was calculated per patient ($847),
which was categorized into equipment ($37), space ($726) and supplies ($94). These average costs were calculated for high
($1,526) and low ($725) acuity patients. The total resuscitation costs for the 96 patients was $79,766.

Discussion

It is feasible to apply principles of TDABC to the measurement of costs of acute trauma care. Digital technology allows this
costing strategy to be applied to all patients in real time, although the accuracy of the method is still limited by our incomplete
understanding of true costs of specific health care commodities. To our knowledge, this is the first application of real time
TDABC in trauma care.

Residents’ Research Day | May 17, 2018 P a g e | 12

OPEN ABDOMEN IN LIVER TRANSPLANTATION

Authors

Chan T, MHSc, MD, Bleszynski MS, MSc, MD, Youssef DS, MD, Segedi M MHSc, MD, Chung S, MD, Scudamore CH, MD,
Buczkowski AK, MSc, MD

Background

Damage control laparotomy with vacuum assisted closure (VAC) is used for selective cases in trauma. In liver transplantation,
VAC has also been applied for management of intra-operative hemorrhage. The primary objective was to evaluate peri-
operative blood loss and blood product utilization in VAC compared to primary abdominal closure (PAC) at the index
transplant operation.

Methods

Retrospective review of all adults undergoing deceased donor liver transplantation (2007-2011) at a single center tertiary care
institution.

Results

201 deceased donor liver transplantations were performed, with 167 PAC and 34 VAC cases. Intra-operative blood loss (4.4L
vs 10.7L), cell saver return (1399ml vs 3998 ml), FFP (7.6U vs 15.9U) and PLT requirements (8.5U vs 18.3U), were all
significantly elevated in VAC compared to PAC. VAC patients had significantly increased RBC, FFP, PLT, and total volume
requirements during initial ICU admission. 30 PAC cases required on demand laparotomy and most commonly for post-
operative bleeding.

Conclusions

In liver transplantation, application of VAC secondary to massive intra-operative exsanguination was safely utilized. Further
evaluation is required to identify long-term morbidity and mortality.

Residents’ Research Day | May 17, 2018 P a g e | 13

PROCESSES AND COMPLICATIONS IN EMERGENCY GENERAL SURGERY

Authors

Huynh C, Laane C, Knebel K, Garraway N, Evans DC, Joos É, Dawe P, MacNeill A, Hameed SM

Background

Emergency General Surgery (EGS) has increasingly been recognized as a distinct surgical subspecialty in North America since
2003. Although the EGS population has been notoriously difficult to define and study, a recent review of EGS systems
described this subset of patients as a unique and severely ill group at high risk of postoperative morbidity and mortality,
making it an important quality improvement target. This study proposes a model to identify ACS patients’ processes and
outcomes, with the ultimate goal of improving quality of care.

Methods

In July 2017, the EGS and Trauma services at the Vancouver general Hospital implemented a new prospective, cloud based
database, populated and maintained by the surgical teams at the point of care. REDCap (Research Electronic Data Capture)
was incorporated into clinical and handover work flow, and used to identify all new consults and operative cases. We
prospectively extracted a 32-day consecutive sample of operative patients with their demographics, diagnoses, operative
interventions and disposition plans from Decmber 11th to January 11th, 2018. A small number of missing patients was retrieved
through attendings’ billing codes. Charts were reviewed to identify patients’ comorbidities and post-operative complications.
Finally, three representative patients were selected for detailed process mapping.

Results

The implementation of REDCap was successful in improving morning handover, enhancing residents teaching and prociding
context for detailed case discussions. We collected demographic, operative and outcome data on 94 EGS patients over a
period of 32 days. The most common comorbidities were a history of previous abdominal surgeries (52.1%), hypertension
(31.9%) and thyroid disease (17.0%). Only 13.8% of patients were previously healthy, with no apparent comorbidities. 35.1%
of patients had postoperative complications which were most commonly identified as prolonged ileus (11.7%), reoperation
(8.5%) and sugical site infections (6.4%). Based on the latter results, process mapping for three specific patients was
performed and revealed potential areas of improvement within the EGS model.

Conclusions

Prospective collection of paitent data improves service handover and creates an important data registry for EGS and Trauma
services. The registry is useful for abetter understanding of perioperative processes and outcomes, idenifying patients and
defining operative cases, and futhermore, it provides a foundation for quality imporvement and research initiatives.

Residents’ Research Day | May 17, 2018 P a g e | 14

LIMITED USEFULNESS OF THE NSQIP SURGICAL RISK CALCULATIOR IN STRATIFYING OPERATIVE RISK IN PATIENTS
UNDERGOING HEAD AND NECK SURGERY

Authors

Joseph Margolick MD, Sam M Wiseman MD FRCSC

Background

We identified rates of reoperation, Emergency Department visits, and hospital readmission after thyroid and parathyroid
surgery at a high volume center. We then determined if scores on the National Surgical Quality Improvement Program Surgical
Risk Calculator (NSQIP SRC) were associated with these events.

Methods

All patients undergoing parathyroid and thyroid surgery between 2011 and 2014 were identified. Those who returned to the
ED, were readmitted to hospital or underwent a second, unplanned operation were reviewed. Data from these reviewed
patients were then inputted into the NSQIP SRC.

Results

436 patients underwent thyroid and parathyroid operations. Rates of re-operations, ED visits and hospital readmissions after
thyroid and parathyroid surgery were: 3.4%, 0.6% and 3.0% and 2.2%, 0% and 1.4%, respectively. 71% of patients who
sustained post-operative complications scored “Below Average” on the NSQIP SRC, 17% scored “Above Average” and 12%
scored “Average risk”. Only 20% of patients who were readmitted to hospital scored above average on the NSQIP SRC for risk
of readmission, the remaining 80% of readmitted patients scored below average risk for readmission. Finally, 25% of patients
who required a reoperation scored above average on the NSQIP SRC for risk of reoperation, while 19% scored average risk and
56% scored below average risk for reoperation.

Conclusions

Overall the sensitivity of the NSQIP SRC was 16.6% for predicting overall complications, 25% for predicting reoperations and
20% for predicting hospital readmissions and therefore demonstrates limited utility in this patient population.

Residents’ Research Day | May 17, 2018 P a g e | 15

LEAD LEVEL MONITORING RETAINED MISSILES ALGORITHM

Authors

Nori Bradley1; Nicole Jedrzejko2; Matt Kaminsky3; Naisan Garraway1

Background

Over 115 000 Americans and 7600 Canadians are injured by firearms annually. In Ontario, youth (< 24 years old) sustain 1
firearm injury per day. Over 70% of shootings are nonfatal, leaving potentially 85 000 North Americans with retained missiles.
Despite reports that 5% of extra-articular retained missiles (EARMs) result in lead toxicity, a paucity of recommendations for
blood lead level (BLL) monitoring exist. Our objective was to develop an evidence-based algorithm for BLL monitoring of
retained missiles.

Methods

We performed a scoping literature review to assess for guidelines and relevant data regarding lead toxicity and EARM.
Trauma, orthopedic and occupational literature was assessed as well as governing body guidelines. We formally searched
Medline/OVID and PubMed and informally queried content experts. Qualitative data synthesis was performed to identify
themes (risk factors) related to lead toxicity from retained missiles. Individual studies were reviewed for discrete data
regarding risk factors to guide development of an algorithm.

Results

Of 225 articles identified, abstract screening and removal of duplicates led to 25 articles that met the inclusion criteria. Most
were case reports or small case series. No formal body provided specific recommendations regarding timing or frequency of
BLL monitoring for retained missiles; most advised “periodic” assessment. Symptoms of lead toxicity did not correlate with
BLL, supporting the need for proactive evaluation. Qualitative data analysis led to the following risk factors for lead toxicity:
anatomic location, increased bullet surface area, duration of exposure, high metabolic demand states, and risk of migration.
Based on individual study level data, an algorithm to guide practitioners for rational BLL monitoring based on risk factors and
assessment triggers is provided.

Conclusions

Current recommendations for retained missiles fail to provide explicit guidelines regarding timing and/or frequency of BLL
monitoring and do not include risk stratification or assessment triggers. Our proposed algorithm may be of benefit to trauma
surgeons, family physicians, rehabilitation medicine physicians, toxicologists and any allied health practitioners involved in the
follow-up care of trauma patients who have sustained gunshot wounds. Further high-quality research in this area is needed.

Specialty: trauma surgery
Topic: public health/preventative medicine
Stage: presented at Trauma Association of Canada Conference 2018 by Bradley, manuscript preparation for submission spring/summer 2018

1Trauma Services, Vancouver General Hospital, Vancouver, BC P a g e | 16
2UBC Postgraduate Residency Program in General Surgery, Vancouver, BC
3Cook County Trauma Unit, Chicago, IL

Residents’ Research Day | May 17, 2018

ARE RESIDENT PHYSICIANS SAFE DRIVERS AFTER EXTENDED-DURATION WORK SHIFTS?

Authors

Mak, N., Li, J., Wiseman, S.

Background

Resident physicians frequently work greater than 24 consecutive hours with very little sleep. The resulting sleep deficit raises
numerous occupational health concerns such as the danger of the post-call commute. A systematic review of the literature
was conducted to investigate the risk of motor vehicle collisions (MVC) and dangerous driving post-call.

Methods

A keyword search was performed for original research articles evaluating any aspect of driving safety following extended-
duration work shifts (EDWS) within the resident physician population were included. Two authors independently reviewed
articles for inclusion. This was followed by independent data abstraction and quality appraisal using the GRADE approach.

Results

Five papers met the inclusion criteria. The quality of the evidence was low to very low. Results were not pooled given the
variability in study approach. Residents reported 2.3 to 3.8 hours of sleep during EDWS. All three survey-based studies found
an increased risk of falling sleeping at the wheel associated with EDWS. Of the studies evaluating the risk of MVCs post-EDWS,
one prospective survey study found an OR 2.3 (95% CI, 1.6 to 3.3) for MVCs post-EDWS and a driving simulation study found a
significant increase in crashes in male residents only.

Conclusions

The period following EDWS poses significant driving safety risks. This is demonstrated by the self-reported driving history of
residents and by simulated driving experiments. Together, these findings call for greater awareness of the significant
occupational and public health risk of the post-call commute.

Residents’ Research Day | May 17, 2018 P a g e | 17

MENTAL TOUGHNESS IN SURGEONS: IS THERE ROOM FOR IMPROVEMENT?

Authors

Dean B Percy MD1, Lucas Streith2, Heather Wong1,5, Chad G Ball MD3, Sandy Widder MD4, Morad Hameed MD1

Importance

Mental toughness is crucial to high level performance in stressful situations. Despite its recognized importance in many other
industries, there is no formal evaluation or training of mental toughness in surgery.

Objective

Determine if there are differences in mental toughness between staff and resident surgeons, and if there is an interest to improve
mental toughness through formal training.

Design

Survey of resident and staff general surgeons. Data included demographic information, and a previously validated mental toughness
questionnaire. Responses were gathered from January to March of 2017.

Setting

Multi-institutional survey at three Canadian residency training sites.

Participants

All currently practicing general surgery staff and residents at each site were eligible.

Main Outcomes and Measures

Self-reported Mental Toughness Index scores measuring eight domains of mental toughness on a seven-point Likert scale converted
to percent positive, as well as use of techniques to perform under pressure and interest in further developing mental toughness
through training.

Results

Eighty-three of 193 surgeons participated; 56/105 (53%) residents, 27/87 (31%) staff, from three Canadian academic institutions.
Average age of residents and staff was 29±5 and 42±8 respectively. Residents scored significantly lower in all mental toughness
domains: Self-Belief (83.4% vs. 91.5%, p<0.001), Attention Regulation (78.1% vs. 89.5% p<0.001), Emotion Regulation (71.9% vs.
87.8% p<0.01), Success Mindset (87.2% vs. 94.2% p<0.001), Context Knowledge (75.0% vs. 88.9%, p<0.001), Buoyancy (79.5% vs.
90.5%, p<0.001), Optimism (77.0% vs. 86.8%, p<0.01) and Capacity to Deal with Adversity (76.8% vs. 84.7%, p<0.05). Males scored
significantly higher than females in Attention Regulation (84.1±11.9%, 77.1±12.8%, p=0.02) and Emotion Regulation (81.6±14.0%,
69.0±13.0%, p=0.001). Age, staff experience and resident post-graduate year were not significantly associated with mental
toughness scores. Thirty-six percent of residents and 56% of staff reported using specific techniques to deal with stressful situations.
Eighty-seven percent of residents and 63% of staff were interested in developing mental toughness.

Conclusions and Relevance

Staff surgeons scored significantly higher than residents in all measured mental toughness domains. Both groups expressed a desire
to improve mental toughness. There are many techniques to improve mental toughness, and further research is needed to assess
their effectiveness in surgical training.

1University of British Columbia Department of Surgery, Division of General Surgery, Vancouver, British Columbia, Canada.
2University of Calgary Faculty of Medicine, Calgary, Alberta, Canada.
3University of Calgary Department of Surgery, Division of General Surgery, Calgary, Alberta, Canada.
4University of Alberta Department of Surgery, Division of General Surgery, Edmonton, Alberta, Canada.

Residents’ Research Day | May 17, 2018 P a g e | 18

COMPARISON OF EARLY POST-OPERATIVE OUTCOMES BETWEEN ASYMPTOMATIC FECAL IMMMUNOCHEMICAL TEST-
SCREENED AND SYMPTOMATIC PATIENTS UNDERGOING SURGERY FOR COLORECTAL CANCER

Authors

S. Khorasani1, S. Al Khaboori2, J. J. Telford3, M. Khorasani1, C. J. Brown2, A. A. Karimuddin2, P. T. Phang2, M. J. Raval2

Background

Colorectal cancer screening programs (CSP) have been show to reduce overall and colorectal cancer (CRC)-specific mortality.
We aimed to compare early postoperative outcomes in patients with asymptomatic Fecal Immunochemical Testing (FIT)-
detected CRC to those with symptom-detected CRC.

Methods

A retrospective review of the prospectively-maintained colorectal cancer database from November 2013 to April 2015 at St.
Paul’s hospital, a high volume, tertiary colorectal surgery referral centre in Vancouver, Canada was performed by two
independent reviewers. All average-risk patients with CRC who underwent surgery were included and were divided into two
groups based on their initial indication for diagnostic colonoscopy: asymptomatic FIT-detected (FIT) vs. symptom-detected
(SYMP) CRC.

Primary outcome was postoperative length of hospital stay (LOS) while secondary outcomes included intra-operative
estimated blood loss (EBL), procedure duration, 30-day postoperative morbidity and mortality. Univariate and multiple
variable analysis, including mixed effects regression analysis to adjust for confounding factors was performed.

Results

186 patients were included (48 FIT, 138 SYMP). FIT patients were significantly older (69.1 +/- 9.3 vs. 64.0 +/- 13.0, p=0.004)
and had significantly earlier stage of cancer at time of diagnosis (p = 0.03). FIT patients had a significantly shorter median LOS
than SYMP patients (6 days [IQR: 5.0-9.0] vs. 7.5 days [IQR: 5.0-13.0], p = 0.04) in univariate comparison and remained
significant in multivariable analysis (p=0.03). Secondary outcomes including procedure duration, EBL and post operative
complications showed no significant statistical difference.

Conclusions

In conclusion, asymptomatic patients who had a diagnosis of colorectal cancer through FIT screening had a significantly
shorter postoperative length of stay compared to those who were symptomatic, lending support to widespread FIT-based
screening programs.

1Department of Surgery, University of Toronto, Toronto, Ontario, Canada
2Department of Surgery, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada
3Department of Medicine, University of British Columbia, St. Paul’s Hospital, Vancouver, British Columbia, Canada

Residents’ Research Day | May 17, 2018 P a g e | 19

THE ESTABLISHMENT OF A TRAUMA REGISTRY IN GONDAR, ETHIOPIA

Authors

Annie Lalande1, Kristin DeGirolamo1, Dessie Yirdaw2, Meron Berhanu2, Shahrzad Joharifard1, Mohammed Alemu3, Miklol
Mengistu3, Mensur Osman3, Naisan Garraway4, Richard Simons4.

Background

Trauma constitutes a major cause of morbidity and mortality worldwide, and its burden is highest in low- and middle-income
countries. Collection of standardized data on trauma patients allows for targeted injury prevention programs, improved
allocation of resources and supports advocacy. A minimal trauma dataset had been deployed in Gondar previously;
unfortunately, data collection had not been sustained. Given an ongoing interest in a registry, another visit was planned. The
objective of this project was to re-establish the trauma registry in the Gondar University Hospital, to identify key players and
interventions to ensure continuity.

Methods

During the field visit in June 2017, focus-group discussions were held with the key interested surgeons and information
sessions were held with the residents and interns, the main data collectors. A statistician joined the team as an archivist
entering the data collected on paper at the bedside into a tablet-based application, creating a standardized trauma registry.

Results

Data collection has been ongoing since the visit in June 2017, with a total of 418 patients currently in the trauma database.
Some of the most significant interventions in ensuring continuity of collection were creating a data flow involving bedside data
collection by the interns, and having access to an archivist with dedicated weekly time for data entry.

Conclusion

Since the last visit, data collection had been sustained and reliable for a few months, though recent difficulties in ensuring
availability of adequate monetary compensation has brought the collection to a halt. Further developments will include re-
establishment of an MOU, on-site observations by the local team to identify common issues leading to decreased data quality,
implementation of solutions and tracking of impact using quality indicators within the registry.

1General Surgery, University of British Columbia P a g e | 20
2General Surgery, University of Gondar
3General Surgery, Gondar University Hospital
4Trauma Surgery, Vancouver General Hospital

Residents’ Research Day | May 17, 2018

TRANSANAL ENDOSCOPIC MICROSURGERY AS DAY SURGERY

Authors

Brown, Carl; St. Paul's Hospital, Gentles, J. Quinn; University of British Columbia Faculty of Medicine, Phang, P Terry; St Paul's
Hospital,
Karimuddin, Ahmer; St. Paul's Hospital,
Raval, Manoj; St. Paul's Hospital

Aim

Transanal endoscopic microsurgery (TEM) is the current treatment of choice for rectal adenomas and early rectal cancer.
Postoperative admission to hospital is common but possibly unnecessary. Our objective was to analyze predictors and
outcomes of TEM patients with same day discharge (TEM-D) compared to those with hospital admission (TEM-A).

Methods

At St. Paul’s Hospital (SPH), demographic, surgical, pathologic, and follow up data has been collected prospectively since TEM
was started in 2007. Trends in admission and readmission rates were analyzed using the Cochran-Armitage trend test, and
predictors of admission were analyzed using univariate and multivariate logistic regression.

Results

Between 2007 and 2016, 500 patients were treated by TEM at SPH. The overall admission rate was 29% (145/500), but
decreased to 19% in the last 3 years of the study (p<0.001). The readmission rate was 5.2% (n=26/500), and did not change
significantly over the study period (p=0.30). Reasons for admission included: surgeon discretion/monitoring (35%), urinary
retention (26%), hemorrhage (10%), breach of peritoneal cavity (7%), infection (7%) and other (15%). The most common
reasons for readmission were hemorrhage (54%, n=14), pain (19%, n=5), and infection (12%, n=3). Factors associated with
admission were: tumour height (OR 1.09, 1.02-1.17), prolonged operative time (OR 1.25, 1.14- 1.37), unsutured surgical defect
(OR 1.99, 1.22-3.25) and surgeon experience (OR 4.62, 2.75-7.77).

Conclusions

Outpatient TEM is safe and carries a low readmission risk. In centers with an outpatient TEM strategy, predictors of hospital
admission include proximal tumours, prolonged surgical time and open management of the surgical defect.

Residents’ Research Day | May 17, 2018 P a g e | 21



SAFETY AND OUTCOMES OF REPEAT TEM

Authors

Ramkumar J1, Letarte F, Karimuddin A, Phang P, Raval M, and Brown, C2,3

Background

Transanal endoscopic microsurgery (TEM) is the treatment of choice for benign rectal tumors and select early rectal cancers.
This surgical approach has become ubiquitous and surgeons are seeing recurrent lesions after TEM resection. This study aims
to outline the safety and outcomes of repeat TEM when compared to primary TEM procedures.

Methods

At St. Paul’s Hospital, demographic, surgical, pathologic, and follow-up data for patients treated by TEM is maintained in a
prospectively populated database. Two groups were established for comparison: patients undergoing first TEM procedure
(TEM‑P) and patients undergoing repeat TEM procedure (TEM-R).

Results

Between 2007 and 2017, 669 patients had their first TEM procedure. Over this time frame, 57 of these patients required
repeat TEM procedures, including 15 of these patients treated by 3 or more TEMs. Indications for repeat TEM included
recurrence (78%), positive margins (15%), and metachronous lesions (7%). There were no differences between the groups in
patient age, gender, or tumor histology. Compared to TEM‑P, TEM‑R had shorter operative times (38 vs 52 mins, p<0.001),
more distal lesions (5 vs 7cm, p<0.004), and smaller lesions (3 vs 4 cm, p<0.0003). The TEM‑R group had similar length of
hospital stay (0.45 vs 0.56 days, p=0.65), rates of clear margins on pathology (81% vs 88%, p=0.09), and 30‑day readmission
rates (7% vs 4%, p=0.27) when compared to TEM‑P group. TEM‑R was more likely to be managed without suturing the
surgical defect (72% vs 32%, p<0.0001). Repeat TEM was associated with similar post‑operative complications as primary TEM
graded on the Clavien‑Dindo classification scale (Grade 1: 5% vs 5%, Grade 2: 5% vs. 4%, Grade 3: 5% vs 1%, p=0.53) No
30‑day mortality occurred in either group.

Conclusions

The St. Paul’s Hospital TEM experience suggests repeat TEM is a safe and feasible procedure with similar outcomes as patients
undergoing first TEM.

1Division of General Surgery, Vancouver General Hospital, 950 West 10th Avenue, Vancouver, Canada. [email protected].
2Department of Surgery, Section of Colorectal Surgery, St. Paul’s Hospital, Vancouver, BC, Canada.
[email protected].
3Section of Colorectal Surgery, University of British Columbia, Room C310, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
[email protected].

Residents’ Research Day | May 17, 2018 P a g e | 23

INTRA-OPERATIVE FROZEN SECTION ANALYSIS OF MARGIN STATUS AS A QUALITY INDICATOR IN GASTRIC CANCER SURGERY

Authors

Hannah Adamson, Nazgol Seyednejad, Howard Lim, Hagen Kennecke, Winson Cheung, Caroline Speers, Andrew F McFadden,
Yarrow J McConnell, Trevor D Hamilton

Background

Malignant disease is the number one cause non-traumatic death within Canada. In 2016, 3,400 people were diagnosed with
gastric adenocarcinoma in Canada, and ultimately 2000 individuals died from the disease. Throughout North America, the
incidence of gastric cancer is decreasing, yet the five-year overall survival remains poor at 30.6%.

Positive pathologic margins following gastric cancer resection carries a poor prognosis. Intra-operative frozen section analysis
may decrease positive margins, but the effect on survival is unclear. While many studies have found that resection margin
status is an independent prognostic factor of worse overall survival, there is conflicting evidence that argue otherwise,
insisting it is an indicator of worse disease or tumour biology.

Given these considerations, the primary objective of this study was to evaluate intra-operative frozen section analysis of
resection margins as a quality indicator in gastric cancer surgery.

Methods

A population-based cohort was constructed including all patients referred to a provincial cancer agency with non-metastatic
gastric adenocarcinoma treated with curative-intent surgical resection between 2004-2012. Clinical, pathologic, and survival
data were collected. Descriptive statistics were utilized to compare baseline characteristics. A multivariate logistic regression
analysis was used to determine factors predictive of a positive surgical margin. Survival analysis was conducted with Kaplan-
Meier curve estimation, log-rank test, and Cox proportional hazards modelling.

Results

377 patients were included in the analysis. Median age was 67 (range 22-88), 67.6% were male, and 49.9% were pathologic
stage III. Pathologically positive surgical margins were noted in 16.2% of cases and were associated with worse overall survival
(16.5 vs. 52.2 months, p<0.001). Intra-operative frozen section analysis of margins was done in 34.0% of cases. Performing
frozen section analysis of margins was protective against a final positive surgical margin (OR 0.34, 95% CI 0.16-0.73, p=0.006),
after adjusting for confounding factors. Frozen section analysis was also associated with improved OS (56.9 vs. 32.6 months,
p=0.01). The OS benefit associated with frozen section (HR 0.72, 95% CI 0.54-0.98, p=0.04) persisted on multivariate analysis.

Conclusions

Patients with intra-operative frozen section analysis of margins were more likely to have negative pathologic margins and had
improved overall survival. This data supports the importance of frozen section as a quality indicator for gastric cancer surgery.

Residents’ Research Day | May 17, 2018 P a g e | 24

A DAY IN THE LIFE OF ACUTE CARE SURGERY IN CANADA

Authors

Kristin DeGirolamo* MD1, Karan D’Souza BSc2, Sameer Apte MD3, Chad G Ball MD4, Christopher Armstrong MD4, Artan Reso MD4,
Sandy Widder MD3, Sarah Mueller MD5, Lawrence M Gillman MD6, Ravinder Singh MD7, Rahima Nenshi MD8, Kosar Khwaja MD9,
Samuel Minor MD10, Chris de Gara MB MS3, Morad Hameed MD1,11.

Introduction

Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies.
Despite the high volume, acuity and complexity of the surgical patient populations served by EGS services, little has been reported
about their structure, process, case mix and outcomes. The purpose of the study was to capture a snapshot at a single point in time
the case mix and workflow during a typical day in EGS across Canada.

Methods

A national cross sectional study of EGS services was conducted simultaneously during a single 24-hour period on January 10, 2017 at
14 hospitals across 7 provinces. Hospitals were recruited through the Canadian Association of General Surgeons Committee on
Acute Care Surgery. Data outlining service structure, patient demographics, operative cases, consults, and admitted patients were
analyzed.

Results

Services were staffed by 1-3 clinicians, with variable resident coverage. All participating sites used a “surgeon of the week” model
where a surgeon suspends their elective practice for a set amount of time to focus on EGS patients while sharing overnight call
responsibility. In contrast to the United States, where trauma and emergency general surgery are often combined in single services,
only 29% of Canadian sites included trauma patients under the scope of EGS services. 71% of sites had at least one half-day per week
of protected operative time available. Additionally, 43% were permitted to use protected time for elective cases.

A total of 387 patient encounters occurred (48.4% operative, 51.6% non-operative). 15.0% were cared for in an intensive care unit
(ICU) setting, and 4.7% had open abdomens. EGS services were newly consulted to assess 112 patients, and 68% of these patients
were admitted within the 24-hr period The patient population was complex with 37% having greater than 3 comorbidities. There
was a wide case mixture including appendectomies (8%) and cholecystectomies (18%), as well as complex emergencies such as
perforations (6%) and obstructions (14%).

Conclusions

Dedicated EGS services are well established across Canada. The characteristics and case mix are heterogeneous, but all services are
busy and provide comprehensive operative and non-operative care to complex, acutely ill patients with high levels of comorbidity.
This study begins a national surveillance effort in EGS to define and advance surgical quality in an important and diverse surgical
population.

1Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada. P a g e | 25
2Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
3Department of Surgery, University of Alberta, Edmonton, AB, Canada.
4Department of Surgery, University of Calgary, Calgary, AB, Canada.
5Department of Surgery, University of Saskatchewan, Saskatoon, SK, Canada.
6Department of Surgery, University of Manitoba, Winnipeg, MB, Canada.
7Department of Surgery, Northern Ontario School of Medicine, North Bay, ON, Canada.
8Department of Surgery, McMaster University, Hamilton, ON, Canada.
9Department of Surgery, McGill University, Montreal, QC, Canada.
10Department of Surgery, Dalhousie University, Halifax, NS, Canada.
11Department of Trauma Services, Vancouver General Hospital, Vancouver, BC, Canada

Residents’ Research Day | May 17, 2018

DUAL-ENERGY COMPUTED TOMOGRAPHY

Authors

Jake Hiebert, Cameron Hague, Sam Wiseman

Background

The objective of this study was to evaluate the performance of dual-energy computed tomography (DECT) for preoperative
parathyroid tumor (PT) localization in primary hyperparathyroid (PHP) patients.

Methods

A retrospective review was carried out of the medical records of all PHP patients who underwent ultrasound (US), Tc-99m
sestamibi noncontrast single photon emission computed tomography (CT-MIBI), DECT and parathyroidectomy at a single
center.

Results

The sensitivities and accuracies for preoperative PT localization in the 97 patient study population were: US 40% and 93%, CT-
MIBI 64.0% and 97%, and DECT 84% and 96%, respectively. In the one third of the study population that did not localize
preoperatively with CT-MIBI and US, DECT correctly localized a PT in 21 cases (66%). DECT and US correctly localized a PT in
86% of cases, and only 5 (8%) of the cases that were accurately localized by a combination of CT-MIBI and US were not
identified by DECT.

Conclusions

DECT should be utilized as a first line preoperative PT localization study in PHP patients, and is also a sensitive salvage
localization test.

Residents’ Research Day | May 17, 2018 P a g e | 26

TREATMENT OF RECURRENT OR PERSISTENT PNEUMOTHORAX IN CHILDREN WITH GLUE PLEURODESIS

Authors

Ma, V., Haddock, C., Skarsgard, E., Heran, M.

Purpose

Primary spontaneous pneumothorax (PSP) resulting from ruptured apical blebs is usually amenable to video-assisted
thoracoscopic surgery (VATS), however there are a subset of patients who are either physiologically intolerant of surgery or
develop recurrent SP after VATS.

The purpose of this study is to report our preliminary experience with a novel technique of localized glue pleurodesis for
recurrent or persistent PSP.

Methods

A retrospective chart review of three pediatric patients treated with glue pleurodesis at our institution for recurrent or
persistent PSP was conducted.

Results

Three patients were treated: two patients (13yo M with Marfan syndrome and 16yo M), developed recurrent PSP after two
previous VATS procedures, while a third (12yo F) patient with chronic systemic lupus erythematosus (SLE) lung disease had a
prolonged air leak, unresponsive to thoracostomy drainage and talc pleurodesis.

All 3 patients were treated with a novel fluoroscopically-guided catheter delivery technique. A 5Fr multipurpose catheter was
advanced to the lung apex, and the existing chest tube was withdrawn. A glue mixture consisting of Histoacryl™ with contrast
was injected over the lung apex, with simultaneous suction applied to the chest tube. The chest tube remained on water seal
overnight and was removed the following morning.

Complete resolution of pneumothorax was observed in all patients. There have been no PSP recurrences at 36, 12 and 5
months respectively.

Conclusion

This small series suggests that glue pleurodesis may be a viable treatment option for recurrent or refractory PSP. Increased
experience and longer followup is required.

Residents’ Research Day | May 17, 2018 P a g e | 27

SCLEROTHERAPY IN THE TREATMENT OF RECTAL PROLAPSE IN CHILDREN

Authors

Graeme Hintz, Vito Zou, Robert Baird

Purpose

Pediatric rectal prolapse is most often treated conservatively, though resistant cases require operative intervention.
Sclerotherapy is a commonly utilized and effective option in this regard. This study systematically evaluates the effectiveness
and complications of various sclerosing agents in treating pediatric rectal prolapse.

Methods

After protocol registration (CRD-42018088980), multiple databases including Ovid [MEDLINE], EMBASE, EBM Reviews,
CINAHL, CAB Direct - Global Health, Web of Science, LILACS, and Grey Literature - Conference Proceedings, were searched
(February 13th, 2018). Studies describing injection sclerotherapy in the treatment of pediatric rectal prolapse were included.
The methodological quality of all included papers was assessed using the Methodological Index for Non-Randomized Studies
(MINORS) criteria.

Results

18 studies were identified, including 964 patients of median age 3.9 years. The most common sclerosing agents analyzed were
phenol in oil, followed by hypertonic saline (56% and 22% of included studies, respectively). The overall success rate after a
single sclerotherapy attempt was 77.4%, with a corresponding recurrence/incomplete resolution rate of 22.6%. The overall
complication rate was 25.7%, with most of these complications being short-lasting fevers. Mean MINORS score of included
studies was 0.63 (with a perfect score being 1).

Conclusions

Injection sclerotherapy appears to be an effective and low-risk treatment option for pediatric rectal prolapse. The available
evidence base is made up of just a handful of articles however, most of which have a relatively poor level of quality.
Prospective comparative investigations are warranted.

Residents’ Research Day | May 17, 2018 P a g e | 28

IS MICRODUCTECTOMY STILL NECESSARY TO DIAGNOSE BREAST CANCER?

Authors

Daniel Ben Lustig, Rebecca Warburton, Carol Dingee, Urve Kuusk, Jin-Si Pao, Elaine McKevitt

Introduction

Patients with pathological nipple discharge (PND) who have neither clinically palpable masses nor evidence of disease on
imaging with mammogram and/or ultrasound are traditionally investigated with galactogram and duct excision. As breast
imaging improves it has raised the question whether galactography and microductectomy are necessary to diagnose breast
cancer. The purpose of this study was to determine the incidence of malignancy in patients presenting with PND who
underwent microductectomy and to evaluate the utility of duct excision and galactography in patients whose initial clinical
and radiological evaluation was negative.

Methods

A ten-year retrospective study was conducted in British Columbia’s largest breast referral center examining the clinical,
radiological and pathological results for all patients who underwent a microductectomy procedure for PND between 2008 –
2017.

Results

A total of 236 microductectomies were performed and the overall incidence of malignancy was 13% (n=31). Following initial
work up, 159 patients (67%) had only discharge on exam and no radiologically suspicious findings of malignant disease. Of
these patients, 14% (n=21) were diagnosed with cancer by duct excision. Galactography yielded a sensitivity and specificity of
64% and 30% respectively (PPV 14% and NPV 82%). Lastly, we found that 3% of patients (n=8) initially diagnosed with benign
disease later developed breast cancer.

Conclusions

Patients with PND should continue to be evaluated with microductectomy to prevent missing a breast cancer. Moreover, we
do not recommend performing galactography for diagnosing breast cancer due to poor sensitivity and specificity though it
may assist in preoperative planning.

Residents’ Research Day | May 17, 2018 P a g e | 29

THE EFFECT OF NEOADJUVANT THERAPY ON THE SURGICAL MANAGEMENT OF BREAST CANCER

Authors
Emily Mackay, Elaine McKevitt, Carol Dingee, Urve Kuusk, Jin-Si Pao, Rebecca Warburton
Background/Objective
Breast cancer management is continually evolving, with a notable change over the past several years being the increased use
of neoadjuvant therapy (NAT). While multiple randomized clinical trials have shown no difference in disease-free survival or
overall survival rates in neoadjuvant versus adjuvant therapy, there are several advantages with the administration of
systemic therapy preoperatively. These include cancer downstaging, conversion to breast conserving surgery in patients who
would have previously required a mastectomy, and performing an in vivo test of tumour response to specific chemotherapy
agents. The effect that NAT has on subsequent surgical interventions has not been specifically examined at our institution. Our
objective is to determine the rate of breast conserving surgery and changes to the management of the axilla following NAT, as
well as the effect of NAT on pathologic complete response (pCR) rates at our institution.
Methods
A review of a prospectively maintained breast cancer database at Mount Saint Joseph Hospital was conducted to identify
patients with invasive breast cancer who received NAT between January 1, 2012 and December 31, 2017. The number of
patients receiving NAT, the percentage of patients undergoing breast conserving surgery, and the primary axillary procedure
performed were examined over time. Rates of pCR were determined, in both breast and axillary specimens, and an analysis
was done to determine patient and tumour factors associated with higher rates of pCR. Statistical analysis was performed
using an unpaired t-test with Welch’s correction; a p-value of < 0.05 was considered significant.
Results
A total of 278 patients were identified with invasive breast cancer that received NAT between the specified time period. Over
time, there was a trend towards more patients receiving NAT. With this, a trend was also seen towards more patients
undergoing breast conserving surgery and sentinel lymph node biopsy as the primary surgical interventions. Overall, total
mastectomy with immediate reconstruction was still the most common intervention. For axillary procedures, axillary lymph
node dissection was the most common, followed by sentinel lymph node biopsy. Of the 79 patients that underwent breast
conserving surgery, 12 (15%) required re-operation either for excision of a positive margin or completion mastectomy.
Following NAT, nodal pCR was seen in 158 patients (58.3%), while breast pCR was seen in 88 patients (31.6%). Patients with
invasive lobular carcinoma were found to have a significantly reduced rate of both breast and axillary pCR in comparison with
those who had invasive ductal carcinoma.

Conclusions
The proportion of patients receiving NAT at our institution has steadily increased over the time period examined. With this, a
trend towards less radical surgical procedures such as breast conserving surgery and sentinel lymph node biopsy has been
observed. The re-operation rate for breast conserving surgery at our institution remains low and is consistent with that
reported in the literature. With further elucidation of the patient and tumour characteristics that are associated with
successful outcomes following NAT and breast conserving surgery, patients can be appropriately selected and counselled on
their options following NAT.

Residents’ Research Day | May 17, 2018 P a g e | 30

IMPACT OF MULTICOLOUR INKING ON PANCREATICODUODENECTOMY MARGINS

Authors
Elizaveta Vasilyeva, Jennifer Pors, Huimin Yang, Peter Kim

Abstract
The definition of the residual tumor status in pancreaticoduodenectomies is a subject of debate. Across various institutions
there is no uniform definition of what constitutes R0 vs R1. Margin status defined as R0 > 1 mm is associated with improved
survival compared to within 1 mm and 0 mm2. The uncinated/SMA margin has been reported as the most commonly involved.
Literature reports rates of R1 between 75-85% when cancer cells are identified within 1 mm of the cut edge2. At the
Vancouver General Hospital, the microscopic margin status was found to be lower, at around 50% (unpublished data). The
purpose of the current study is to determine if inking the specimens intraoperatively by the primary surgeon compared to
inking in the pathological department makes a difference in the terms of reported rate of microscopic positivity and the type
of the margin that is the most commonly reported positive.

1. Esposito I, Kleeff J, Bergmann F, Reiser C, Herpel E, Friess H, Schirmacher P, Buchler MW. Most Pancreatic Cancer Resections are R1 Resections.
Annals of Surgical Oncology, 2008; 15(6):1651–1660.
2. Strobel O, Hank T, Hinz U, Bergmann F, Schneider L, Springfeld C, Jager D, Schirmacher P, Hackert T, Buchler MW. Pancreatic Cancer Surgery. The
New R-status Counts. Annals of Surgery, 2017; Volume 265 (3): 565-573.

Residents’ Research Day | May 17, 2018 P a g e | 31

ROTEM – GUIDED DETECTION OF HYPERCOAGULABILITY IN PATIENTS WITH TRAUMATIC BRAIN INJURY

Authors

Joos, E., Garber, K.A., Garraway, N., Gooderham, P., Trudeau, J., and Smith, T.

Background

Trauma patients have a high risk of venous thromboembolism (VTE), contributing to a significant morbidity and mortality in
these patients. Pharmacologic VTE prophylaxis is recommended in all major trauma patients. However, in TBI patients the
progression of intracranial hemorrhage may be catastrophic. In light of this concern, initiating pharmacological VTE
prophylaxis in TBI patients is not currently standard of care. Thromboelastometry (TEM), may provide an objective measure of
when a TBI patient becomes at higher risk of VTE. Our study aims to use TEM to determine the incidence and timing of
hypercoagulability in TBI patients, with the ultimate goal to find an objective measure of VTE risk in this patient population.

Methods

A prospective feasibility pilot study will be undertaken at VGH from June to December 2019. We aim to recruit 50 adult
patients from a single center, with moderate to severe TBI. TEM parameters along with standard coagulation tests will be
recorded at several time intervals over their hospital stay. Incidence of VTE will be recorded for these patients, along with
mortality and morbidity data.

Residents’ Research Day | May 17, 2018 P a g e | 32

MORBIDITY AND FUNCTIONAL OUTCOMES IN OLDER PERSONS UNDERGOING MAJOR ABDOMINAL SURGERY

(Research in progress)

Authors

Mak, N., Brasher, P., Jones, G., McGregor, M.J., Mayson, K., Warnock, G.

Background

Following major surgery, frail patients are estimated to have 5 times the odds of mortality and 2 times the odds of major
morbidity. The implications of surgical intervention on the function and quality of life of frail persons is less clear. This
prospective cohort study aims to evaluate preoperative frailty as a predictor of poor postoperative surgical outcomes and
patient-reported functional and quality-of-life outcomes after abdominal surgery.

Methods

This is a single-centre study for patients above the age of 70 years old undergoing NSQIP-tracked abdominal surgery
procedures. Baseline frailty, functional status, and quality of life are measured using standardized assessment tools. At 30
days and 3 months following their operation, telephone follow-up is conducted to assess changes from baseline. Outcomes
relating to morbidity and mortality will be obtained through data linkage to the NSQIP database.

Results

A pilot of the study whose primary objective was to evaluate the study’s process was conducted. A total of 34 patients were
eligible for inclusion based on age and procedure. Eight patients were ineligible due to language. Recruitment rate for eligible
patients was 52%. The primary reasons for declining participation was the study’s time requirements. Two out of 13
participants withdrew at the time of baseline assessment, citing length of questionnaires as a deterrent to continued
participation. Average total time to complete baseline assessment was 24.5 minutes (s.d. 4.2 min). Telephone follow-up at 30
days was complete.

Conclusions

Although follow-up completion rate was satisfactory, recruitment rates for the study were low. The protocol is feasible from a
resource perspective but requires modification. The study’s recruitment process should be improved by reducing the burden
of questionnaires.

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