The study, recently published in JAMA Surgery, looked at 1.3 million patients treated by nearly 3000 surgeons between 2007 and 2019 in Ontario, measuring adverse postoperative outcomes such as death, readmission and complications 30 days following a surgical procedure. The researchers analyzed associations between surgeon-patient sex concordance (male surgeon with male patient, female surgeon with female patient) or discordance (male surgeon with female patient, female surgeon with male patient). They looked at outcomes following 21 different procedures in a variety of surgical specialties.

“Previous research in the emergency care setting has shown that sex discordance, particularly among male physicians and female patients, can be associated with some adverse effects,” says Dr. Angela Jerath, one of the co-authors of the study and an anesthesiologist and scientist at Sunnybrook. “We were interested in exploring whether this was similarly the case in regards to surgical outcomes.”

The researchers found that female patients were 15% more likely to experience adverse outcomes following common surgical procedures when treated by a male rather than a female surgeon. When a male surgeon operated on a female patient – compared with a female surgeon – there was a 32 per cent increase in the likelihood of a female patient’s death in the 30 days following the procedure. In contrast, for male patients, there was no difference in outcomes whether they were treated by female surgeons or male surgeons.

Dr. Angela Jerath, co-author of the study and anesthesiologist and scientist at Sunnybrook Health Sciences Centre.

“These results are concerning because the sex of patients and surgeons should not result in differences in patient outcomes after surgery,” says Dr. Jerath. “As an anesthesiologist I know there are many excellent male surgeons who consistently have good outcomes. However, at a population level, the analysis does signal a concerning difference between male and female surgeons overall and its impact on patient outcomes, which needs to be explored.”

The researchers say more work is needed to determine the cause of the disparities. Dr. Christopher Wallis, who co-led the study explains it’s unlikely the findings are the result of technical difficulties between sexes. “Both male and female surgeons undergo the same technical medical training. The very large sample size and the examination of many different surgical specialties would have diluted any technical differences between male and female surgeons. We believe there are other complex factors at play,” says Dr. Wallis, a urologic oncologist in the Division of Urology at Mount Sinai Hospital and University Health Network.

The authors propose implicit sex biases, differing communication or interpersonal skills which may influence trust, and variations in decision making and clinical judgement as potential factors contributing to the disparities.

“Previous research has also shown that symptoms reported by female patients may be under-appreciated in the health care setting (particularly among male physicians). Thus, early symptoms of complications may be missed when they can be mitigated and instead manifest as more severe events,” says Dr. Wallis.

The researchers add the study highlights the need to diversify the workforce to better serve the patients they are treating. “This work really emphasizes the importance of changing the culture of medicine to promote the role of women in our field,” says Dr. Wallis.

Although more research is needed, the authors say their advice to patients is to ensure they have a good, trusting relationship with their surgeon regardless of sex. “The patient-surgeon relationship is extremely important,” says Dr. Jerath. “Patients want to ensure they can openly discuss their questions and concerns before, during and after surgery.”

Read more about the research in The Guardian, U.S News, and CTV News.

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It was an event that captured the collective attention of 900 of the world’s leading gynecologists. On May 16, 2019, three surgeries performed at Sunnybrook were videocast live to a medical conference in Montreal – a Canadian first.  

Over three hours, this international audience at the annual meeting of the Society of Endometriosis and Uterine Disorders (SEUD) witnessed Sunnybrook’s leading approaches to operative hysteroscopy, laser treatment of endometriosis and hysterectomy. A team of surgeons wore microphones and headphones, allowing conference moderators to direct audience questions in real time to doctors in the three operating rooms.

“We were able to answer questions on our techniques and ways to reduce patient complications,” says Sunnybrook surgeon Dr. Grace Liu, part of the SEUD organizing committee. “Thanks to positive audience feedback, this could set a new precedent for future videocasts from other hospitals.”

More than 50 Sunnybrook staff from various departments worked together for almost a year to make the videocast happen.

“It was a team effort within Sunnybrook and with the event producers, to organize the technical and logistical aspects for this broadcast,” says Doug Nicholson, assistant manager in digital and visual communications at Sunnybrook. “Events like this help share the advances happening here.”

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A new study published today in JAMA Network Open found that patients in Canada and the U.S. who underwent one of four common surgical procedures filled opioid prescriptions within a week after discharge at a rate that was nearly seven times higher than patients in Sweden.

The study – which focused on adults who underwent gallbladder removal, appendix removal, meniscus repair and breast lump removal – is the first of its kind to systematically evaluate the differences in the use of opioids after surgery for patients receiving similar procedures in different countries.

About 76 per cent of the U.S. patients and nearly 79 per cent of the Canadian patients filled a prescription for opioids after their surgery, versus just 11 per cent of Swedish patients.

Dr. Hannah Wunsch is a staff physician in the department of critical care medicine at Sunnybrook and a co-author of the study. Below, we asked her more about how the study came together, which findings most surprised her, and what we can learn from Swedish prescribing practices.

How did you become interested in studying opioid prescription rates?

As a pharmaco-epidemiologist, I’m always interested in the question of, “what medications are people getting?”

The majority of my work has focused on critically ill patients. Years ago, it became clear that there was an opioid epidemic happening, but at the time the focus was very much on the community and elicit use of opioids. I noted that, although we use opioids every day in clinical practice in both surgery and critical care, no one was talking about or looking at prescribing practices in those settings, and how it might impact patients and the wider communities. That has, of course, now changed as many studies have come out looking at the question of prescribing practices.

Why did you choose to compare Canada to the US and Sweden? 

We knew we wanted to compare prescribing practices in Canada and the US to see how similar or different they looked. We also knew we wanted to look at some other country in Europe, as we hypothesized that prescribing practices would look very different. We did spend some time trying to identify a country which we knew would have pretty comprehensive data on prescribing for everyone in the country, and also have data that would be readily accessible. So, we identified a few potential options we explored, but it was a little bit of serendipity that we were introduced to our Swedish colleagues, and they were able to access the data for this project.

How did you decide to study those four low-risk surgeries in particular?

We spent a lot of time thinking about procedures. We wanted them to be common, so that we would have a lot of patients in each country, not frequently done in conjunction with other procedures or be associated with other medical conditions (such as cancer) that might make it hard to determine what prescriptions were due to the surgery versus other concerns. We also wanted them to be procedures that did not involve a prolonged hospital stay, so that we wouldn’t have the problem of what people received over days and days in the hospital.

Were you surprised by any of the findings?

We were surprised by a number of the findings. First, we were surprised at how similar Canada and the US were in terms of prescribing practices. I think there is still the perception that because the US has the “bigger” opioid problem in terms of overdoses and deaths, that the filling of prescriptions after surgery would be more frequent than in Canada.

The second big surprise was the magnitude of the difference in Sweden. To some degree, this was a study of demonstrating what people thought they already knew, namely that opioid use is much lower in many European countries after surgery. However, no data really demonstrated that for sure, and we certainly didn’t know just how different it would be: a 7-fold difference in rates of prescriptions filled.

The study mentions that some prescribers (incorrectly) view tramadol and codeine as “safer” opioid alternatives. How did that become such a prevalent view, and what could be done to change it? 

Both drugs are relatively low potency, meaning that an individual pill generally contains “less” opioid than some other opioids we prescribe. For that reason, many people view them as “weak”. However, both drugs rely on metabolism to generate active metabolites, which can be variable between people, making it hard to predict an individual’s response to either of these drugs. The use of the term “weak opioid” is also a concern, as the adjective lulls people into assuming it’s safer. One way to try to improve education is to move away from the terms “strong” and “weak” to describe opioids to remove that sense of security.

Tramadol is not a controlled substance in Canada, which likely makes it feel safer to people, and makes it easier to prescribe. On the other hand, it is not covered by the prescription drug plan in Ontario, so individuals have to pay for it themselves if it is prescribed. Undoubtedly, this variability in scheduling and coverage influences the prescribing patterns we see when comparing the different countries.

The study found that patients in Canada and the US filled opioid prescriptions within the first seven days after discharge at a rate nearly 7-fold higher than individuals in Sweden. What are Swedish prescribers doing differently? Is there anything we can learn from them?

This study leaves a lot of unanswered questions. For example, we don’t know what individuals in Sweden are told when they are discharged, or what degree of pain they experience, or whether they were satisfied with their care and their pain control. However, we have no reason to think these aspects of surgical care are inadequate in the Swedish system. So, I think the main thing we can learn is that there is the potential to do things differently and to consider whether at least some of our patients are receiving unnecessary prescriptions.

I think it is helpful to see a model of care that is so different, as it is proof that alternative approaches are potentially viable options. A fantastic opinion piece was published in the New York Times in January, 2018 that describes the experience of an American receiving surgery in Germany, and the different approach to post-operative opioid prescribing that she experienced. I view that piece as the anecdote that confirms our results.

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A: Just a quick refresher: The large intestine, or colon, is the final part of the digestive tract and its job is to absorb water back into the body and create waste. The colon is an average length of about 1.5 metres with the final 15 cm being the rectum and then the final sphincter muscle that controls the stool is the anus.

To answer your question in a nutshell, usually most of the colon is left alone and only the section with the cancer is removed, and the two ends are brought together to create a connection. Imagine it like cutting out a damaged part of a garden hose and reattaching the two ends.

Let’s explore the details of this kind of surgery more below.

Location, location, location

How the colorectal cancer surgery is done is essentially based on location. At the time of the colonoscopy, the colorectal cancer is diagnosed and the exact location is the cancer is identified. This is the critical information the surgeon will use to plan the surgery. There are lots of other factors that determine how much colon should be removed to treat the cancer.

Distance: The most important consideration is the safe distance from the cancer to make absolutely sure that there are no cancer cells left behind; this is called the margin. Studies have shown that in colon cancer, the resection lines should be about 10 cm away from the cancer on both sides. In rectal cancer, if the cancer is low in the rectum and very close to the anus, we accept as little as a 1 cm margin if it means that we can reconstruct the intestine and not remove the anus. If the cancer is at the sphincter muscle and involving the anus or very close to it, than the entire anus must be removed and in those cases a permanent stoma is necessary (which I’ll describe in more detail in another post.)

Lymph Nodes: The colorectal cancer resection also must include all the lymph nodes or glands that surround the tumour. A pathologist examines the removed nodes after the surgery to see if cancer cells had travelled to the nodes. This helps us decide which patients require chemotherapy after the surgery.

Anatomical considerations: There are other things we look at in order to plan the operation, and this is determined by understanding the blood flow to the colon. After a segment of the colon is removed, it is extremely important that the two ends that are used to make the new connection have a very good blood supply in order to make sure they heal to each other and there is no leak from the connection. To be sure the blood supply to the two ends of colon is ideal, there are very defined sections of the colon we remove and we are very particular about the location of the two ends that we bring together. Another critical anatomic consideration that the surgeon must be certain of is that the two ends that are brought together to reconnect are under absolutely no tension whatsoever, as this also may lead to a leak in the connection.

Based on all these factors, the surgeon will decide what segment of the large intestine they will need to remove in order to:

• Be absolutely certain the cancer is completely removed with all its associated nodes.
• Optimize the chances of healthy well-healed reconnection of the two ends.

Therefore the surgery can entail removal of the right or left side of the colon, sigmoid colon, upper rectum, entire rectum, or even the entire rectum and anus. These surgeries are all described here.

Open surgery or laparoscopic?

The surgeries for colorectal cancer removal can be done both open and laparoscopically. Open surgery involves a large vertical incision in the middle of the abdomen and the operation is done through this cut. Laparoscopic surgery involves placing a tiny camera in the belly button (umbilicus) and three tiny incisions in the abdomen. We use long surgical instruments, and do the operation by looking in the abdomen via the camera on a large screen.

When possible and safe, and in the right setting, the laparoscopic approach is, quite frankly, better. Much less pain, shorter recovery, shorter time in hospital and no wound issues. Many large trials have shown that the cancer results are the same for open and laparoscopic surgery, as long as the surgeon is comfortable with that approach and has ample experience and volume of cases. My personal opinion is that laparoscopic surgery for colon cancer should be the standard of care. Having said that, many cancers are not safe to remove laparoscopically because they are too large, or they are stuck to other organs, or the patient has had many other surgeries and there is too much scar tissue. But the laparoscopic approach should always be considered and discussed.

Inside my OR

In my practice about 90 per cent of the surgeries are done laparoscopically so I’ll explain that in a bit more detail:

Step 1 – Insufflation: we insert a small metal tube into the belly button and through it we blow air into the abdomen. This air gives us a working space by separating the abdominal wall from all the organs. We then insert the camera into this space.

Step 2 ­­– Surgical Access: we insert three more small metal tubes into the abdomen. We place our very long, thin surgical instruments through these tubes. We control the instruments from outside the abdomen but they function inside the abdomen. We can see everything in the abdomen through the camera.

Step 3 – Decision Making: we identify the exact area that needs to be removed by looking at the cancer and then considering all the factors mentioned above in order to decide on exactly where we will cut.

Step 4 – Resection: using a tiny mechanical stapler that slides into the metal tubes, we cut both ends of the colon. The stapling device seals the colon closed before cutting, so there is no contamination. We ensure when we remove it that we’ve included all the lymph nodes surrounding it.

Step 5 – Reconstruction: we first cut away any scar tissue to loosen the two ends so they will come together easily now that a segment has been removed. Then with a combination of stapling and sewing, we make a new connection of the two ends of colon.

Step 6 – Extraction: we make a small cut through the skin to remove the diseased segment of the colon from the abdomen and this ends the procedure.

This step-by-step list makes it all sound very straightforward — and it certainly can be for early small cancers in favourable locations. But it can also be very complex and require much more involved surgeries to get the cancer out and create the best possible chance to cure the colorectal cancer. In very rare occasions for cancers that are too close to the end to make a connection, a permanent pouch for stool can be required.

If you have questions about your specific surgery, please feel comfortable to talk to your surgeon. Ask questions until you understand. It is your body, and you have the right to understand what the surgery will entail.

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The Answer: I am sorry to hear that your wife’s colorectal cancer has spread. And I can understand why you are looking at different options outside of standard chemotherapy. Sunnybrook has been offering the DEBIRI treatment (intra-arterial infusion of irinotecan-loaded drug-eluting beads) for about two years and while it extends survival significantly, it is not a cure. On average, the Sunnybrook team performs this procedure once or twice a month.

Eligible patients are those with cancer that has spread to the liver that is not surgically operable and has not responded to at least two standard systemic chemotherapy drugs. Typically, these patients have diffuse tumours on their liver – sometimes in a rain shower pattern – making surgical removal impossible.

With DEBIRI, also known as liver chemoembolization, beads are threaded through a small catheter line from the blood vessel into the artery, located in the groin, that supplies blood to the liver. These tiny beads contain a very highly concentrated dose of the chemotherapy drug irinotecan. With this treatment, the blood vessels are partly blocked with the beads, starving the tumor of its blood supply, while concentrating chemotherapy in high doses to the tumours. This devastating “one-two punch” slows, and in some cases, even halts tumor growth.

A small, single institution phase III of a clinical trial of 74 patients randomly assigned to receive DEBIRI (36) versus systemic irinotecan, fluorouracil and leucovorin (FOLFIRI, 38), found a survival advantage for patients who use the treatment, compared to those who use standard intravenous therapy, according to a 2012 study published in the journal, Anticancer Research. The study, while limited, demonstrates the potential DEBIRI has in the treatment of metastatic colorectal cancer.

“It is hard for me to say whether she is a candidate or not without more details,” said Calvin Law, head of the cancer surgery program at Sunnybrook. “We really think that DEBIRI should be examined on a case-by-case basis.”

A team that includes a radiologist, medical oncologist, radiation oncologist and surgical oncologist select what patients would benefit from the treatment.

“If we all agree,” said Dr. Law, “then the interventional radiologist will look at the picture and tell us if they can put the beads in the right place.”

If the treatment is recommended, it takes place in two sessions, usually weeks apart. Each time, the patient is in hospital for two nights and three days. Return to work is widely variable – from as low to a week to a month or longer.

“Typically, there is more than one treatment and occasionally, there are more than three treatments,” said Dr. Law.

The post When Cancer Spreads and Standard Therapy No Longer Works appeared first on Your Health Matters.

The Answer: The “wait and see” surgical list is ubiquitous to Canadian hospitals. That’s because a hospital, with finite resources, must operate at or near occupancy to be efficient in the public health care system. This is in stark contrast to the United States, which has the ability to treat a paying patient more quickly in a private system where hospitals, in some cases, are only half full and are looking for business.

Since your father came through emergency department, he did not have a booked operation. He was deemed clinically stable, put on an intravenous fluid to keep him hydrated, then placed in a queue for the operating room. This is probably the most frustrating part for patients. He will wait for some time – hours, sometimes several days – to move up the queue, knowing that as a trauma hospital, a more injured person coming here will be jettisoned to the top of the list. Conversely, a booked surgery may be cancelled, and your father may quickly be seen.

Still, your point is a good one: you simply want to know why he wasn’t fed and when a surgeon makes “the call” to say your father can now eat, then try the next day to get into the operating room.

“On the acute units, we depend on the call from the surgical team for further information about the planned surgery,” said Smitha Casper-DeSouza, patient care manager. “As soon as we know, we inform the patients/families.”

Patients on the “wait and see list” include those with fractures, diverticulitis, gallbladder issues or bowel obstructions.

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I was about nine years old, decked out in my Sunday best, preparing with the rest of my grade school choir to belt out some holiday songs for the packed house of anxious and proud parents attending the Christmas concert. A quiet hush washed over the audience as we took our place on the risers and the lights dimmed. As our music teacher took her place in front of us and got ready to cue the first line of Silent Night, you could hear the proverbial pin drop. The only sound that broke it was the cracking joints of middle-aged parents bending down to capture the moment on film.

Don’t ask me why I remember that, but I do. It was simply gross to me at the time. Today, as life has a cruel way of doing, things have come full circle. My joints are increasingly verbal. And while (knock on wood) they are still functioning well, I realize that I’m smack in the middle of a demographic that is increasingly indicated for joint replacement surgery. Dr. Jeffrey Gollish, a top orthopedic surgeon at the Holland Centre says, we’re seeing a real shift in who is going under the knife. Those aged 55 used to be the exception. Today, they make up nearly a third of patients getting new parts, so to speak.

Part of the change comes from advances to the joint replacement components, with most functioning better and lasting 15 years or more the Holland Centre has also advanced the understanding of when surgery is needed, knowing that the lower people start out on the functional scale, the worse they fare even after surgery. So when your midlife crisis collides with joint replacement surgery, please don’t feel alone.

I know that crackling joints don’t mean surgery is in the cards, but a decline in your daily functioning certainly warrants an assessment. So does an increasing reliance on pain relieving medications. As one of the largest hip and knee replacement centres in Canada, the Holland recently won an award for their model of care, which cuts down on wait times and streams patients into the level of care they need: surgery, physiotherapy or otherwise.

Get more information about the Holland Centre’s programs and services, no matter how old or young you are.

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They say life happens when you’re busy making other plans. For Joel Shafer, that came with a cruel twist of timing. Two days before his birthday, and two days after his wedding anniversary, he got the unexpected news that he had prostate cancer. Faced with the reality of now what, Joel started doing his homework. Having recently settled into retirement, this certainly wasn’t what he’d hoped to be filling the hours with.

The statistics sound like background hum until you are the one in six affected (or the countless spouses and family members trying to steady the waters). Deciding on a course of treatment is different and difficult for every man, trying to weigh the balance between what can be both a deadly and slow growing cancer.

For Joel, after much consideration, surgery was his choice. So he embarked a treatment path that’s delivered to about 200 men a year here at Sunnybrook Health Sciences Centre: complete prostate removal, known in medical speak as radical prostatectomy.

Dr. Robert Nam is one of the top surgeons in Canada doing this procedure. I sat in on one of his surgeries last week, and watched him deliver what he calls the ‘Nam Deluxe’: a delicate sparing of nerves around the prostate, allowing the vast majority of men to recover with little to no impact on their urinary or erectile function over time. (There’s a reason the term “surgical precision” has made it into our vocabulary. Having witnessed it firsthand, I think Dr. Nam had a lot to do with it.)

Joel is now several months post-op, and doing very well. I met with him at his home in a well-established neighborhood. Family photos adorning the walls, he now hopes to get back to the business of being retired. For men facing the same diagnosis he did only months ago, he encourages them to read up and reach out to those who have been there. Understand you should take a little time before you make any decisions, he told me. And when all is said and done, you put your faith in the doctors and the process.

Did you know?

Men should have a PSA test done at age 50, or earlier if they have a family history of prostate cancer. Make sure to complete Sunnybrook’s Prostate Cancer Risk Calculator with your family doctor.

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UPDATE – July 2014: Sunnybrook helped in the early development of this system, now known as GestSure.

Sunnybrook’s Dr. Calvin Law remembers driving to Montreal with his father years ago. Sitting in the passenger seat, Dr. Law was in charge of navigating. Too bad he fell asleep. Map in lap, they missed the proper exit by more than the proverbial mile. Today, he uses this story to explain the importance of bringing a cool new gaming system into his operating room.

Until now, surgeons like Dr. Law have been using their own “maps” in the operating room: images of the patient that help guide each surgery. But these were located on computers outside the sterile zone, making for a big fat inconvenience. “There was this gap between two huge advances. One was just getting better at surgeries. And also, all the advances we’ve made in imaging, but they need each other,” Dr. Law told me. “And where was the bridge to bring them together?”

Turns out, that bridge was the Xbox Kinect, which interprets body movements into a language the computer understands, removing the need for a remote control. This is perfect for the operating room because it means surgeons don’t have to leave the sterile field to check scans of the patient. In short, it becomes a hands-free GPS system in surgery.

“So what the Xbox Kinect allowed us to do was, with the wave of our hands, all of the sudden the computer is with us, the images are right in front of where we are working, and we’re able to bring that computer as if it were the last member of our team, right into the working field of the operating room.”

How cool is that?

I watched, intrigued, as Dr. Law demonstrated the system for me outside Sunnybrook’s surgical suites. Arms in the air, he gently moved them around and down, in turn manipulating the brain scan pulled up on the computer screen 5 feet away. It’s not a sight you see everyday, attracting equal ribbing and admiration from fellow surgeons walking by. Undeterred by the tai chi jokes, Dr. Law continued on, telling me that this will change the way surgeons interact with imaging in the operating room, potentially forever. “It’s really given us a new way to work with the images without breaking sterility or obviously putting our patients at risk.”

It’s funny where the seeds of genius ideas are planted and in this case, when two long-time friends were out for a jog. Matt Strickland, a general surgery resident was telling his engineer friend Jaime Tremaine about the need for accessing CT, MRI and other scans during surgery. Knowing the Xbox Kinect had potential beyond gaming, they consulted another engineer friend, Greg Brigley. A few roles of electrical tape later, and voila, they were able to bring fun and games into the operating room! Dr. Law was more than happy to try it out.

So far, this application has been tested in about a dozen patients with great results, helping save time and expedite the flow of surgery. Dr. Law says, even he was surprised at how quickly and naturally it was picked up by staff and students. He says this application will be especially important in cancer surgery, where attacking so-called enemy tumors precisely will benefit a patient’s quality of life and overall recovery by sparing healthy surrounding tissue. It’s like hitting the bulls eye every time.

Another benefit? Dr. Law was having a blast. And who doesn’t want a happy surgeon? Unlike the trip to Montreal, there’s no getting lost with this in the operating room.

Learn more about how surgeons are using the Xbox

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