Resident Research Corner
Canadian General Surgery residents don't just provide outstanding patient care while training to be clinical experts, they also engage in a number of research activities. These efforts help advance many fields from basic sciences to clinical epidemiology to medical education to health policy research. The Resident Research Corner highlights some of the strong work going on across the country.
Have a question about the Resident Research Corner? Send it to Ashley Drohan, the program coordinator and a resident at Dalhousie University, at Ashley.Drohan@dal.ca.
Derek Roberts, PGY4
Residency Program: University of Calgary
Supervisors: Dr. David Zygun, Dr. H. Thomas Stelfox
Date: March 2017
Derek Roberts is a fourth-year General Surgery Resident and the Efficiency, Quality, Innovation, and Safety (EQuIS) Research Fellow at the University of Calgary in Calgary, Alberta. EQuIS is a multidisciplinary group of clinicians and researchers interested in improving the quality and efficiency of surgical care provided in Calgary, Canada, and internationally.
Derek completed a Bachelor of Science in Pharmacy (and practiced as a pharmacist for three-years) and an MD with Distinction at Dalhousie University in Halifax, Nova Scotia in 2005 and 2009, respectively. After then pursuing two-years of general surgery residency training at the University of Calgary, he completed a Residency in the Clinician Investigator and Surgeon Scientist Programs, a PhD in Epidemiology, and a KT Canada Strategic Training in Health Research (STIHR) Graduate Training Program/Fellowship at the same institution in 2015. Trainees awarded a KT Canada STIHR Fellowship receive formal graduate training in the science and practice of KT. KT is an evolving clinical science that attempts to bridge the gap between “what we know” and “what we do” in medicine and surgery by ensuring that clinicians are aware of and effectively use research evidence to inform their healthcare decision making.
After completing his general surgery residency in June of 2018, Derek hopes to pursue fellowship training in vascular and endovascular surgery and a career as a KT-focused surgeon-scientist.
As opposed to single-stage or definitive surgery, “damage control surgery” is a potentially life-saving surgical approach that allows the initial trauma surgical operation to be abbreviated after control of bleeding and gross contamination from gastrointestinal tract or pancreaticobiliary injuries using one or more “damage control interventions.” This allows surgeons to restore the pre-injury status or physiology of the patient in the Intensive Care Unit before returning to the operating room for additional surgery.
Although damage control surgery may improve survival in select, severely injured patients, its use is associated with a number of complications, and therefore should only be used when appropriately indicated. The overall objective of Derek’s PhD thesis was therefore to identify and evaluate candidate indications for use of damage control surgery and damage control interventions in civilian trauma patients. As a key predictor of the success of a research program aimed at developing indications in trauma patients may be the coproduction of knowledge with knowledge users, we purposively built relationships with and among surgical practice leaders in the United States, Canada, Australia, New Zealand, Europe, and South Africa. Using this integrated KT intervention, these leaders were involved in the research from the setting of questions through to the interpretation of the resultant data.
To summarize the research described in Derek’s PhD thesis abstract (available at: http://theses.ucalgary.ca/handle/11023/2206): To identify the circumstances in which damage control surgery may be appropriately used, we conducted a scoping review. Of 27,732 citations identified by the search, we included 270 articles that reported 1,107 indications for DC surgery and 424 indications for 16 different thoracic, abdominal, pelvic, or vascular DC interventions (Roberts et al. Indications for use of damage control surgery and damage control interventions in civilian trauma patients: a scoping review. J Trauma Acute Care Surg 2015;78(6):1187-96). We conducted a content analysis to synthesize these indications into 123 codes representing unique indications for damage control surgery (Roberts et al. Indications for use of damage control surgery in civilian trauma patients: a content analysis and expert appropriateness rating study. Ann Surg 2016;263(5):1018-27) and 101 codes representing unique indications for 16 different DC interventions (Roberts et al. Indications for use of thoracic, abdominal, pelvic, and vascular damage control interventions in civilian trauma patients: a content analysis and expert appropriateness rating study. J Trauma Acute Care Surg 2015;79(4):568-79). An international panel of trauma surgery experts subsequently assessed 101 (82.1%) of the coded indications for damage control surgery and 78 (77.2%) of the coded indications for damage control interventions to be appropriate for use in modern civilian trauma care. We conducted a systematic review to identify studies reporting data on the reliability or validity of indications and, among 31,014 indications identified, we included 36 studies that evaluated 79 unique indications. Of these, only nine had evidence supporting that they were associated with improved survival (manuscript in the peer-review process). Finally, we conducted a cross-sectional survey of trauma centers and surgeons located in the United States, Canada, Australia, and New Zealand (Roberts et al. Opinions of practicing surgeons on the appropriateness of published indications for use of damage control surgery in trauma patients: an international cross-sectional survey. J Am Coll Surg 2016;223(3):515-29). In total, 232 (64.8%) trauma centers responded. These centers nominated 366 surgeons to survey about indications for damage control surgery, of whom 201 (56.0%) responded. Respondents assessed 15 (78.9%) preoperative and 23 (95.8%) intraoperative indications to be appropriate. These indications provide a practical foundation to guide practice while studies are conducted to evaluate their impact on patient outcomes.
Researcher: Sean Bennett, PGY3
Residency Program: University of Ottawa
Supervisors: Dr. Guillaume Martel, Dr. Dean Fergusson
Date: February 2017
Sean did his undergraduate training in Kinesiology as well as medical school at Dalhousie University. In between the two he also spent a year completing an M.Sc in Adapted Physical Activity in Leuven, Belgium, studying the outcomes of deep brain stimulation of the subthalamic nucleus in patients with Parkinson’s disease. He has completed 2 clinic years of General Surgery training at uOttawa, and then entered the CIP and the M.Sc Epidemiology program. He has recently returned to full-time clinical training.
In addition to his main research area regarding the role of red blood cell transfusions in patients undergoing liver resection, Sean has published work on selective non-operative management of stable penetrating abdominal trauma, the role of routine preoperative upper endoscopy in bariatric surgery, and intraductal papillary neoplasms of the biliary tract. He intends to pursue a career in HPB Surgical Oncology.
Liver resection is commonly associated with significant blood loss and subsequent red blood cell transfusion. This has trended down over the past few decades with improvement in surgical and anesthetic techniques as well as evidence from many areas of medicine of the detrimental effects of transfusion. Perioperative transfusions are still given in about 1 in 4 liver resections. Sean’s thesis work included 3 components: a systematic review, a provider survey, and a study of transfusion appropriateness.
The systematic review of the effects of blood transfusion in patients undergoing liver resection demonstrated the lack of good quality evidence. Given the available evidence, there does seem to be a true association between transfusions and increased post-operative complications, independent of known confounders. The potential association with long-term cancer recurrence is equivocal, and there appears to be no association with increased post-operative mortality. This work was recently accepted for publication in HPB.
A provider survey of Canadian anesthesiologists and liver surgeons was circulated, elucidating interesting findings and differences in perioperative blood management and decision-making regarding blood transfusions.
The major component of the thesis was a study of transfusion appropriateness, using the RAND/UCLA Appropriateness Method. This is essentially a two-iteration consensus conference of a multi-centre, multi-disciplinary expert panel to determine the clinical scenarios for which a blood transfusion would be appropriate or inappropriate. The end result of which has created the Ottawa Criteria for Appropriate Transfusions in Hepatectomy (OCATH) – to be published in Annals of Surgery.
Researcher: Eric Goudie, PGY4
Residency Program: Université de Montréal
Supervisors: Dr. Moishe Liberman
Date: January 2017
Eric completed his medical degree at University of Montreal where he currently is a PGY-4 in general surgery. He is part of the Clinician Investigator Program and is undertaking a Doctorate in Biomedical Sciences. His research interests focus on energy devices in thoracic surgery. He has presented his work at several national and international meetings. He is first author and co-author on many peer-reviewed publications and has participated in writing a book chapter on the present and future application of energy devices in thoracic surgery. He has received the CIHR Frederick Banting and Charles Best Canada Graduate Scholarship and a scholarship from the Fonds de Recherche du Québec – Santé. Eric is planning on pursuing his training in thoracic surgery after his general surgery residency.
Anatomical lung resection is the primary treatment strategy for operable stage I and II non small cell lung cancer. Lobectomy is either performed by thoracotomy or by video assisted thoracoscopic surgery (VATS). VATS lobectomy is associated with a shorter postoperative length of stay, and significantly less postoperative atrial fibrillation, blood transfusion, renal failure, and other complications when compared with lobectomy via thoracotomy. The two approaches were found to have similar 5-year survival rates.
VATS lobectomy complications include pulmonary vascular injuries (pulmonary artery, pulmonary vein) necessitating urgent conversion to open thoracotomy and even death. Published conversion rates range from 2% to 20%. Pulmonary artery (PA) branch manipulation, stapling and division are the main technical difficulties and danger in VATS lobectomy. Major pulmonary vessel hemostasis in thoracoscopic surgery, including the PA, is typically achieved using endo-staplers. These staplers fire six rows of staples and simultaneously cut in the middle; leaving 3 rows of staples on each side. The staplers are bulky, rigid and have a large footprint making application and stapling of pulmonary vessels awkward, difficult and dangerous. PA manipulation with the endo-staplers is one of the main hesitations of many thoracic surgeons regarding the adoption of VATS lobectomy. According to an analysis using the Nationwide Inpatient Sample (NIS) database in the United States, only 15% of anatomical lung resections were performed by VATS in 2013.
Energy sealing devices are currently safely used to seal and divide systemic vessels, but not for the pulmonary artery. In a pilot study recently published by our group, energy sealing devices achieved effective vascular sealing on an ex-vivo model with the ability to sustain high intraluminal bursting pressures. Sealing and dividing blood vessels with these devices require less manipulation of the vessel, less dissection, and are finer than staplers to apply. Hence, we believe that if we can decrease the manipulation and dissection required by the surgeon on the PA branches, we can make VATS lobectomy safer and therefore more prevalent for anatomical pulmonary resections.
We conducted an animal survival study. We performed 10 VATS lobectomies in 10 adult dogs. All the steps of the procedure were similar to a standard human VATS lobectomy, except for PA branch. We sealed and divided all PA branches with an ultrasonic energy vessel-sealing device. The dogs were kept alive for 30 days and followed for any hemorrhagic complications. All dogs survived 30 days without hemothorax. Necropsy at 30-days did not reveal any signs of post-operative bleeding. Pathology of the sealed PA branches at 30-days revealed fibrosis, giant cell reaction, neovascularization and thermal changes of the vessel wall.
We are currently recruiting patients in a human trial using an ultrasonic energy vessel-sealing device for VATS lobectomy. These results bring new safety data for an eventual widespread clinical utilization of this technology. This has the potential to make VATS lobectomy more prevalent.
Researcher: Gavin Tansley, PGY3
Residency Program: Dalhousie University
Supervisors: Dr. Natalie Yanchar
Date: December 2016
Gavin Tansley completed his undergraduate studies and medical training at the University of British Columbia before moving to the opposite coast for General Surgery residency at Dalhousie University. There Gavin completed two years of postgraduate clinical training before entering the Clinician Investigator Program. Within this program Gavin completed a Masters of Public Health at the London School of Hygiene and Tropical Medicine as well as a Masters of Medical Research based at Dalhousie University. His research focuses on using geospatial methods to understand the influence of spatial factors on the care of injured patients in both high and low-income settings.
Trauma is one of the leading contributors to the burden of disease in Canada, accounting for nearly 15,000 deaths and $20 billion in healthcare expenditures annually. Several studies have previously confirmed that timely care at designated, high volume trauma centers has a positive impact on this disease burden by reducing trauma-related mortality. However, concentrating resources at discrete geographic locations has the unintended consequence of reducing the accessibility of these resources for subsets of the population. This may have significant implications for trauma system design, but currently the relationship between trauma care accessibility and outcome is poorly understood.
Using geospatial statistical methods to combine population-based trauma registries with injury and hospital locations, Gavin’s research attempts to clarify the relationship between access to trauma care and outcomes. Ultimately this research aims to identify populations with the poorest access to trauma care as well as the subsets of the injured population who are most significantly affected by poor access to care. Gavin’s studies involve both high- and low-income settings, and he hopes the results of his research will inform the structure and design of the trauma systems he studies.
Researcher: Janice Austin
Residency Program: University of Calgary
Supervisors: Dr. Lloyd Mack, Dr. May Lynn Quan, and Dr. Elizabeth Oddone Paolucci
Date: March 2016
Background: Janice completed her Bachelor of Science with Honours in Biology and Chemistry at the University of Toronto Scarborough Campus. She then went on to complete her Medical Degree at the University of Toronto. She is currently in her final year of General Surgery at the University of Calgary and will be commencing a Fellowship in Surgical Oncology at the University of Toronto in July 2016. Her clinical research is therefore focused in surgical Oncology. In addition, she has a strong interest in education and is completing her Master’s Degree in Medical Education through the University of Calgary. She is heavily involved in several residency committees as well as medical education research.
Janice alongside her supervisors has conducted and published studies on bootcamps medical education, surgical treatment of superficial soft tissue sarcoma, and breast cancer in young women (manuscript in preparation). These studies have been presented at the Canadian Surgery Forum (London, 2011 and Vancouver, 2014) as well as the ASCO Breast Cancer Symposium (San Francisco, 2014). She was also awarded funding by the Carol May Yates Memorial Endowment in 2012 for research in breast cancer.
Research Summary: Janice’s most recent study examined young women with breast cancer. Breast cancer in young women is aggressive. Delays in diagnosis and treatment may contribute to the worse outcomes observed in the treatment of breast cancer in young women. The objectives of Janice’s research were 1) to determine if there was diagnostic or treatment delay for women ≤ 40 with breast cancer in Alberta and 2) to describe treatment patterns for women ≤ 40 with breast cancer in Alberta. Diagnostic delay was defined as time from first imaging showing an abnormality to pathologic diagnosis of >90 days. Treatment delay was defined as time from pathologic diagnosis to commencement of first treatment modality of >45 days.
The above objectives were achieved through a retrospective population based review of women ≤ 40 treated for breast cancer between 2007 and 2010. Patients were identified through the Alberta Cancer Registry.
This study found that 4% (15/347) of young women in Alberta had a delay in diagnosis. Delays were most often due to inconclusive imaging with recommendations for follow up imaging. Women with diagnostic delay more often underwent single imaging with ultrasound rather than imaging with both mammogram and ultrasound. Approximately 7.5% (26/347) of young women experienced a delay in treatment. Delays in diagnosis or treatment were not associated with higher rates of recurrence or death.
Janice is currently working on a meta-analysis of preventable adverse events in surgery and is conducting a survey to measure the perceptions and practice of surgeons with respect to how patient safety is taught at the University of Calgary using a Knowledge, Attitudes, and Practice (KAP) assessment.
Researcher: Amanda Hall
Residency Program: University of Saskatchewan
Supervisors: Dr Grant Miller and Dr Gordon Zello
Date: February 2016
Background: Amanda is a general surgery resident at the University of Saskatchewan and is currently in the fourth year of her PhD through the Clinician Investigator Program. Her graduate work focuses on parenteral nutrition associated liver disease. In the course of her PhD program she has published a chapter on parenteral nutrition associated disease in infants in the text book Parenteral Nutrition: Policies and Procedures, Safe Practices and Potential Complications, (Nova Science Publishers Inc. 2014). She has also conducted a study separate from her main thesis investigating the aluminum levels in current neonatal parenteral nutrition (manuscript under review). Amanda has presented her research at the 2014 CAGS resident retreat and she looks forward to presenting at the 2016 American Society of Parenteral and Enteral Nutrition conference in January. After residency, she hopes to pursue a fellowship in pediatric surgery and continue nutrition-based research.
Research Summary: Parenteral nutrition associated liver disease: the effects of aluminum contamination and lipid composition on bile acid transporter proteins.
Long term parenteral nutrition (PN) places newborn infants at risk of parenteral nutrition associated liver disease (PNALD), but the pathophysiology of this condition is still unknown. We theorize that both pro-inflammatory lipids and aluminum contamination contribute to PNALD. We hypothesize that by decreasing aluminum contamination and reversing pro-inflammatory lipid profiles, we can obtain the best preservation of bile acid transporters, thus preventing PNALD.
In partnership with Memorial University, we have conducted two randomized control trials using a newborn Yucatan miniature pig parenteral nutrition model. We have selected four bile acid transporters, and two supporting proteins as targets for this study. These targets will be examined by real time polymerase chain reaction (qPCR) to evaluate mRNA expression, immunofluorescence confocal microscopy to evaluate the localization of the bile acid transporters and Western blot to determine final protein presence. To date, we haveqPCR evidence that indicates the apical transporters (Mrp2 and Bsep) are both damaged by aluminum. The qPCR fold differences were 1.8 (SD 0.8) and 4.3 (SD 2.7) respectively, in favour of the low aluminum vs the high aluminum group. (Greater than 1.5 is significant). Further analysis is ongoing.
This work was made possible through grants from the Children’s Hospital Foundation of Saskatchewan, NSERC, and the University of Saskatchewan Department of Surgery.
Researcher: Jonathan Cools-Lartigue
Residency Program: McGill University
Supervisors: Lorenzo Ferri MD PhD
Date: December 2015
Personal statement: Jonathan is currently completing his fifth year of surgical residency in the department of General Surgery at McGill University. After completion of his general surgery training, I will pursue a fellowship in cardiothoracic surgery at Memorial Sloan Kettering in New York. During his training, he has remained active in both clinical and basic scientific research. In particular, he is currently in the process of completing a PhD in Experimental surgery through the Surgeon Scientist Program at McGill University under the supervision of Dr. Lorenzo Ferri. His research interests are focused in the field of thoracic oncology as reflected in numerous publications in both the clinical and basic research domains. His PhD thesis has focused primarily on elucidating the mechanisms by which systemic inflammation promotes tumor progression in patients with lung and esophageal malignancies. In particular, this work has contributed greatly to the understanding of the role of neutrophil extracellular traps in circulating tumor cell sequestration and tumor progression. This work represents a completely novel process and an exciting potential avenue for therapeutic intervention in the future. Most notably, the publications arising as a result of his doctoral thesis (Journal of Clinical Investigation – August 2013) have been widely reported in the global lay media including National Public Radio, Australian Broadcasting Corporation, and Radio Canada. In addition, this research was cited as one of the top 10 discoveries of 2014 by Quebec Science magazine.
Research Summary: The majority of patients with cancer undergo at least one surgical procedure as part of their treatment. Severe postsurgical infection is associated with adverse oncologic outcomes; however, the mechanisms underlying this phenomenon are unclear. Emerging evidence suggests that neutrophils, which function as the first line of defense during infections, facilitate cancer progression. Neutrophil extracellular traps (NETs) are extracellular neutrophil-derived DNA webs released in response to inflammatory cues that trap and kill invading pathogens. The role of NETs in cancer progression is entirely unknown. We report that circulating tumor cells become trapped within NETs in vitro under static and dynamic conditions. In a murine model of infection using cecal ligation and puncture, we demonstrated microvascular NET deposition and consequent trapping of circulating lung carcinoma cells within DNA webs. NET trapping was associated with increased formation of hepatic micrometastases at 48 hours and gross metastatic disease burden at 2 weeks following tumor cell injection. These effects were abrogated by NET inhibition with DNAse or a neutrophil elastase inhibitor. These findings implicate NETs in the process of cancer metastasis in the context of systemic infection and identify NETs as potential therapeutic targets.
Researcher: Ramin Kholdebarin, Fellow in MIS/Bariatric Surgery, University of Ottawa
Residency Program: University of Manitoba
Supervisors: Dr. Richard Keijzer
Date: November 2015
Ramin completed a Bachelor of Science in biochemistry at the University of British Columbia. He went on to study medicine at Queen’s University, where he developed an interest in clinical research. Through the support of research scholarships from Queen’s University, Ramin pursued summer research projects at the University of Toronto. These efforts led to publications titled “Risk Factors for Bile Duct Injury During Laparoscopic Cholecystectomy” and “Multicenter Study of Compliance and Drop Administration in Glaucoma”.
As a resident in general surgery at the University of Manitoba, Ramin continued his interest in clinical research by studying the effects of a newly formed Acute Care Surgery Service on surgeon quality of life and resident education. While pursuing further research opportunities during residency, Ramin met Dr. Richard Keijzer, a paediatric surgeon with an interest in translational research. Dr. Keijzer is trying to understand the pathophysiology of congenital diaphragmatic hernia and how it leads to pulmonary hypoplasia. Ramin completed a Master’s of Science in surgery under the supervision of Dr. Keijzer. Ramin’s research has led to multiple publications in peer reviewed journals and presentations at national conferences including Canadian Surgery Forum, Canadian Association of Paediatric Surgeons and Canadian Society of Surgical Oncology.
Congenital diaphragmatic hernia (CDH) is a developmental defect in the diaphragm that leads to herniation of abdominal viscera into the chest cavity. Children born with this condition have small lungs (pulmonary hypoplasia), which is a source of major morbidity and mortality. The pathophysiology of pulmonary hypoplasia is poorly understood and the majority of cases do not have a genetic predisposition. Dr. Keijzer has studied microRNA expression in CDH lungs from humans and found increased expression of miR-200b. To further study the role of miR-200b in lung development, we developed a technique for mapping microRNA expression in tissues from a rat model of CDH and surprisingly found decreased expression of miR-200b.
This conundrum was solved when we looked at miR-200b expression in response to Fetoscopic tracheal occlusion (FETO) therapy in utero. FETO ameliorates pulmonary hypoplasia by preventing egress of fluid out of the lungs during embryonic development. miR-200b expression was increased in response to therapy and miR-200b levels could predict survival following treatment. Therefore, we concluded that miR-200b upregulation is a compensatory response to the deleterious effects of CDH. This response occurs naturally in human CDH and is further enhanced by intrauterine therapy. This finding also helped explain differences in the characteristics of pulmonary hypoplasia in humans vs. the rat model that have been known for some time. This project is a good example of how translational research, correlating clinical data to basic science research, can enhance our understanding of human diseases.
Researcher: Chris Blackmore
Program: University of Calgary
Supervisors: Dr. Elizabeth Oddone-Paolucci, Dr. Steve Lopushinsky and Dr. Jocelyn Lockyer
Date: September 2015
Chris completed his Bachelor of Science in Biology at the University of Calgary before going on to complete medical school at the University of Alberta. He is currently in his final year of general surgery at U of C.
During residency training, he developed an interest in medical education through his interactions with medical students and junior residents. This interest led him to take part in both small group and classroom teaching at the UofC medical school. Ultimately, he took off time between 2nd and 3rd year of residency to complete a Master of Science in Medical Sciences with a specialization in Medical Education through the UofC.
His main educational research interests are curricular design and transitions in medical education. He recently presented his research on the effectiveness transitional “boot camps” at the International Conference on Resident Education.
After residency, Chris will be heading to Halifax to pursue a fellowship in pediatric surgery at Dalhousie University.
Recent Research: Targeted needs assessment for a transitional “boot camp” curriculum for pediatric surgery residents
Introduction: Transition periods in medical education are associated with increased risk for learners and patients. For pediatric surgery residents, the transition to training is especially difficult as learners must adjust to new patient populations. In this study we perform a targeted needs assessment to determine the ideal content and format of a pediatric surgery boot camp to facilitate the transition to residency.
Methods: A needs assessment survey was developed and distributed to pediatric surgery residents and staff across North America. The survey asked participants to rank 30 pediatric surgical diagnoses, 20 skills, and 11 physiological topics on two domains: “frequency” and “importance”. Items were then ranked using empirical methods. The survey also evaluated the preferred boot camp format.
Results: In total, 12 residents and 23 staff completed the survey. No significant differences were identified between staff and residents in survey responses. The top 5 ranked topics identified for inclusion in a pediatric surgery transitional boot camp were: (1) fluid and electrolyte management, (2) appendicitis, (3) pediatric hernias, (4) nutrition and (5) pain management. The preferred format for a boot camp was 3–4 days in duration. For the physiological topics and pediatric surgical diagnoses, the preferred educational methods were problem based learning and e-learning, while for skill based topics the preferred educational methods were low and high fidelity simulation.
Conclusions: Based on the results of the needs assessment survey, a novel pediatric surgery boot camp curriculum can be developed.
Further details on Chris’s research can be found as follows:
1. Blackmore, C., Austin, J., Lopushinsky, S., and Donnon, T. The Effects of Post Graduate Medical Education “Boot Camps” on Clinical Skills, Knowledge and Confidence: A Meta-Analysis. J Grad Med Ed 2014; 6(4):643-652.
2. Blackmore C, Lopushinsky S, Lockyer J, Oddone Paolucci E. Targeted needs assessment for a transitional “boot camp” curriculum for pediatric surgery residents. J Ped Surg 2015; 50(5):819-824.
Researcher: Robert Wu
Program: University of Ottawa
Supervisors: Robin Boushey, Dawn Stacey, Joseph Mamazza
Date: July 2015
Robert Wu did his undergraduate medicine training at the University of Toronto. He is currently completing his surgical residency training at the University of Ottawa and has recently finished his Masters degree in epidemiology in the Clinical Investigator Program. He wishes to explore and augment the role of shared decision-making in surgical interventions.
He was involved in a range of research projects during his residency. His thesis project focused on the evaluation of the rectal cancer patient decision aid on patients facing low anterior resection versus abdominoperineal resection, as well as the factors influencing its implementation in clinical practice as perceived by surgeons. Based on 32 patients with rectal cancer within 10 cm from the anal verge,
they had poor baseline knowledge (52.5%) and improved by 37.5% (p < 0.0001) after using the patient decision aid. At baseline, no patients preferred a permanent stoma, and after decision aid exposure, 2 patients (7.1%) preferred permanent stoma. Over 96% of participants would recommend the patient decision aid to others. Based on survey results with a 46.7% response rate, half of the
respondents (51%) reported that they were either “very likely” or “likely” to use the decision aid. Although majority agreed the decision aid is well developed and would be valuable to patients, commonly perceived barriers were time constraint, need for
multiple visits, and additional personnel.
This research project was awarded the Physicians’ Services Incorporated Resident Research Grant. It has been presented at the 2014 CSF Symposium in Vancouver, 2014 American College of Surgeons Clinical Congress in San Francisco, and 2015 American Society of Colon and Rectal Surgeons meeting in Boston. The decision aid is currently being implemented at the Ottawa Hospital Cancer Assessment Centre.
He is also coordinating the INOPAIN trial exploring the use of intraperitoneal Ropivacaine during laparoscopic bariatric bypass surgery to reduce postoperative pain. The trial aims to recruit 120 patients with two parallel arms of intraperitoneal Ropivacaine vs. normal saline infusion over laparoscopic Roux-en-Y anastomosis prior to surgical dissection. Postoperative pain, opioid use, peak expiratory flow, and walk distance are the endpoints assessed at regular intervals. The study is ongoing and results are expected shortly.
Researcher: Markus Ziesmann
Program: University of Manitoba
Date: May 2015
Markus Ziesmann completed a Bachelor of Science degree majoring in Biochemistry before attending medical school at the University of Manitoba. He enrolled in the Bachelor of Science in Medicine research program and successfully defended his thesis work describing fifteen years of local experience managing paediatric cardioembolic strokes. Upon graduation, Markus entered the General Surgery residency program at the University of Manitoba and is currently the program’s Chief resident. During residency he took on several administrative roles including serving on the Board of Directors for both the Canadian Association of Internes and Residents (2011-2012) and Doctors Manitoba (2012-2013) and was the Co-President of the Professional Association of Residents and Interns of Manitoba (2012-2013). Upon graduating in 2016, he plans to pursue both trauma surgery and critical care fellowships, working towards a career as an academic acute care surgeon.
Markus’s MSc thesis work focused on the development and validation of a quantitative quality-assessment tool for the FAST exam. Current training in FAST exam technique lacks validation; in an era of competency-based training, validated assessment tools will be increasingly important. The proposed quantitative assessment metrics for the FAST exam included a global rating scale and task-specific checklist, each measuring specific domains of FAST exam performance, coupled with objective hand motion analysis measures including number of hand movements and total path length of hand travel. Cohorts of novice and expert FAST performers were recorded performing the exam and subsequently scored using the assessment metrics.
Experts scored significantly higher than novices on all eight domains of the global rating scale and three out of four domains on the task checklist, while completing the task with a shorter path length of travel and making fewer movements. The global rating scale and task checklist demonstrated extremely high discriminatory power, with areas under the receiver operating characteristic curves of 97% and 90% respectively. Thus, these metrics were shown to be valid measures for assessing FAST imaging competence which will be useful for defining training standards in a competency-based curriculum, for comparing FAST skill with clinical outcomes, and for assessing the success of training interventions.
This research was funded by the University of Manitoba Department of Surgery GFT Research Fund, and has been presented at the 2014 meetings of the Trauma Association of Canada and the American Association for the Surgery of Trauma. For this work, Markus was a finalist in the University of Manitoba Three Minute Thesis competition, and was awarded the AAST Research and Education Foundation In-Training Fellow Scholarship. Portions of this research have been published as “Validation of the Quality of Ultrasound Imaging and Competence (QUICk) score as an objective assessment tool for the FAST examination” by Ziesmann et al, May 2015, in the Journal of Trauma and Acute Care Surgery.
Researcher: Gabrielle Gauvin, PGY3
Program: Queen\'s University
Supervisors: Dr C. Jay Engel and Dr. Gabor Fichtinger
Date: April 2015
Gabrielle completed her Bachelor of Science with Honors in Biopharmaceutical Science as well as her medical degree at the University of Ottawa. She is currently in her 3rd year of General Surgery residency at Queen’s University. Along with clinical research, she also has a great interest in medical education and is involved in several education committees. She developed a surgery orientation handout for medical students and junior residents. She also started a sustainable program to involve the residents in the surgical clerks’ orientation process. She presented her work at the Canadian Undergraduate Surgical Education Committee (CUSEC) podium session of the Canadian Surgery Forum (Vancouver, 2014): \"Starting the day off right: residents’ role in orienting surgical clerks\". Following residency, Gabrielle plans to pursue a clinical fellowship in Surgical Oncology.
Research Summary: Breast-conserving surgery using real-time electromagnetic navigation
Breast cancer is treated during its early stages with breast-conserving surgery. Accurate delineation of the tumor margin is difficult as most lesions are not palpable, and breast tissue deforms during surgery. Current strategies, including gold-standard wire-localization, have positive margin rates as high as 47%. We propose using real-time electromagnetic (EM) tracking to three-dimensionally delineate and track the tumor resection volume, allowing the surgeon to navigate around the tumor and improve the precision of the resection. The EM navigation system utilizes an ultrasound (US) to register the tumour resection volume from a tracked needle fixed in the tumor, allowing tumor movement to be followed in real-time during surgery. This method has the potential to reduce the incidence of positive margins, while reducing the amount of healthy tissue removed.
We first performed a study using PVC phantom breast models created to simulate breast tissue density and deformability. We saw a reduction in the positive margin rate from 42.9% in the control group to 19.0% in the EM navigation group. A second study was done on cadavers to improve the workflow on real breast tissue. A clinical feasibility study is being conducted on patients with a palpable tumor to test the ease of use of EM navigation in the operating room setting. This study currently shows no EM-specific complications or breach in sterility. Feedback questionnaires state that none of the participants find that the EM sensors interfere with the surgical procedure, and that the EM navigation is easy to use.
These studies have led to presentations in Canada: Canadian Surgery Forum (Vancouver, 2014); USA: American Miami Breast Cancer Conference (Miami, 2015), Image Guided Therapy Workshop (Cambridge, 2014); International: Computer Assisted Radiology and Surgery (Barcelona, 2015), Hamlyn Symposium on Medical Robotics (London, 2014). The poster \"Real-Time Electromagnetic Navigation for Breast Tumor Resection: Proof of Concept\" presented at the Canadian Surgery Forum (Vancouver, 2014) wonthe best poster award for the Canadian Society of Surgical Oncology category.
Queen’s Department of Surgery Development and Innovation Fund internal department grant was awarded to co-fund the palpable tumor study. An Academic Health Science Center (AHSC) Alternate Funding Plan (AFP) Innovation grant was recently awarded by the Southeastern Ontario Academic Medical Organization (SEAMO) to fund the next phase of this project, a clinical trial to see if EM navigation reduces the rate of positive margins in breast-conserving surgery for non-palpable tumors. As a plug, if you are interested in participating the next step: multi-center RTC, please contact CJay.Engel@krcc.on.ca.
Researcher: Elena Parvez, PGY5 (March 2015)
Researcher: Jean-Michel Aubin, PGY-5 (November 2014)
Researcher: Timothy Rice, PGY-5 (October 2014)
Researcher: Lakhbir Sandhu, PGY-4 (May 2014)
Researcher: David Al-Adra, PGY-7 (April 2014)
Researcher: James Villamere, PGY-5 (March 2014)
Researcher: Amin Madani, PGY-3 (February 2014)
Researcher: Jon Bailey, PGY-3 (January 2014)
Researcher: Ramzi Helewa, PGY-6 (December 2013)
Researcher: Ram Anantha, PGY-4 (November 2013)
Researcher: Derek J. Roberts, PGY-3/CIP (September 2013)
Researcher: Rashmi Seth, PGY-5 (July 2013)
Researcher: Harry Kim, PGY-4 (June 2013)
Researcher: Sean Bennett, PGY3
Residency Program: University of Ottawa
Supervisors: Dr. Guillaume Martel, Dr. Dean Fergusson