Papers by Christopher Gara
Public health reports (Washington, D.C. : 1974)
This study sought to determine if (1) using a hands-free technique (HFT)--whereby no two surgical... more This study sought to determine if (1) using a hands-free technique (HFT)--whereby no two surgical team members touch the same sharp item simultaneously--> or = 75% of the time reduced the rate of percutaneous injury, glove tear, and contamination (incidents); and (2) if a video-based intervention increased HFT use to > or = 75%, immediately and over time. During three and four periods, in three intervention and three control hospitals, respectively, nurses recorded incidents, percentage of HFT use, and other information in 10,596 surgeries. The video was shown in intervention hospitals between Periods 1 and 2, and in control hospitals between Periods 3 and 4. HFT, considered used when > or = 75% passes were done hands-free, was practiced in 35% of all surgeries. We applied logistic regression to (1) estimate the rate reduction for incidents in surgeries when the HFT was used and not used, while adjusting for potential risk factors, and (2) estimate HFT use of about 75% and ...
Canadian Journal of Surgery, 2015
Endoscopy services and training: a national survey of general surgeons Background: Delivering hig... more Endoscopy services and training: a national survey of general surgeons Background: Delivering high-quality endoscopy services depends largely on the competence of endoscopists. General surgery residency training in endoscopy and the associated quality of endoscopy services being delivered by general surgeons have been the subject of considerable controversy. In conjunction with the Canadian Association of General Surgeons (CAGS) executive board, we formulated a survey to evaluate the general state of endoscopy practice and training among general surgeons in Canada. Methods: The study was designed as a cross-sectional survey. General surgeons who are members of CAGS were selected to participate in the study and were emailed a link to the online questionnaire regarding the importance of endoscopy. They were asked to compare their training to resident training today. Results: Sixty-nine surveys were completed. The majority of general surgeons (95.7%) indicated that endoscopy was an important skill to possess, and more than 85.5% used endoscopy in their own practices. However, nearly half (46.4%) felt that general surgery endoscopy training in Canada is currently inadequate to produce competent endoscopists. The main qualitative themes emerging from the survey were the inadequacy of current postgraduate endoscopy training (37.5%) and the absence of standardization in training (25.0%). Conclusion: Endoscopy is considered integral to academic and community general surgeons' practices; however, the adequacy of training seems to be questioned. Postgraduate training in endoscopy needs to be formalized and standardized, with a greater emphasis placed on teaching endoscopy.
Not So Routine Follow-up
Academic Medicine, 2009
That Monday morning at the clinic started out like any other-the buzz of nurses directing patient... more That Monday morning at the clinic started out like any other-the buzz of nurses directing patients to examination rooms, overhead pages filling the air, and residents milling about before the start of their clinics. A few hours into my morning rounds, I had developed a ...
American journal of surgery, 2013
Making a conflict of interest declaration is now mandatory at continuing medical education CME ac... more Making a conflict of interest declaration is now mandatory at continuing medical education CME accredited events. However, these declarations tend to be largely perfunctory. This study sought to better understand physician perceptions surrounding conflict of interest. The same PowerPoint (Microsoft, Canada) presentation (http://www.youtube.com/watch?v=mQSOvch7Yg0&feature=g-upl) was delivered at multiple University of Alberta and Royal College CME-accredited events to surgeons, internists, and learners. After each talk, the audience was invited to complete an anonymous, pretested, and standardized 5-point Likert scale (strongly disagree to strongly agree) questionnaire. A total of 136 surveys were analyzed from 31 surgeons, 49 internists, and 56 learners. In response to the question regarding whether by simply making a declaration, the speaker had provided adequate proof of any conflicts of interest, 71% of surgeons thought so, whereas only 35% of internists and 39% of learners agree...
Gastroenterology Research and Practice, 2013
Background. Obesity is well known for being associated with significant economic repercussions. B... more Background. Obesity is well known for being associated with significant economic repercussions. Bariatric surgery is the only evidence-based solution to this problem as well as a cost-effective method of addressing the concern. Numerous authors have calculated the cost effectiveness and cost savings of bariatric surgery; however, to date the economic impact of weight regain as a component of overall cost has not been addressed.Methods. The literature search was conducted to elucidate the direct costs of obesity and primary bariatric surgery, the rate of weight recidivism and surgical revision, and any costs therein.Results. The quoted cost of obesity in Canada was $2.0 billion–$6.7 billion in 2013 CAD. The median percentage of bariatric procedures that fail due to weight gain or insufficient weight loss is 20% (average:21.1%±10.1%, range: 5.2–39,n=10). Revision of primary surgeries on average ranges from 2.5% to 18.4%, and depending on the procedure accounts for an additional cost b...
The impact of a formal mentoring program for minimally invasive surgery on surgeon practice and patient outcomes
The American Journal of Surgery, 2007
Surgeons need a process by which to safely introduce new procedures, such as minimally invasive s... more Surgeons need a process by which to safely introduce new procedures, such as minimally invasive surgery (MIS), into practice. Emerging evidence would suggest that an effective strategy is the implementation of a mentorship program. This study analyzed the effect of mentoring on a single institution's advanced MIS practice. We analyzed clinical outcomes by completing a retrospective review of patient charts 1 year before and 1 year after the recruitment of a fellowship-trained advanced MIS surgeon in July 2004 whose job description included facilitating the introduction of advanced gastrointestinal MIS. A total of 7 general surgeons were mentored at 1 site. After 1 year of intense mentoring, the number of surgeons completing >12 cases/y increased from 2 to 4, and the number of advanced MIS cases completed (excluding mentored ones) increased from 35 to 102. Fifty-three cases (52% of total) were formally mentored. Total conversions to open surgery decreased from 14.3% to 6.4% (P = .12). The number of colorectal resections increased from 11 to 92 (P = .0027). Intraoperative complications were not significantly decreased, eg, from 17.1% to 7.1% (P = .06). Postoperative complications remained unchanged (15.0% to 16.5%). Surgeons and the institutions in which they work have a duty to adopt advanced MIS techniques in a safe and appropriate manner. We believe our data demonstrate that a mentorship program is an effective strategy for safely introducing advanced MIS into practice.
The American Journal of Surgery, 2003
Background: Exposure to blood and body fluids while operating places surgeons at risk. Double glo... more Background: Exposure to blood and body fluids while operating places surgeons at risk. Double gloving is a safety measure, which decreases this risk. However, many surgeons do not incorporate this precaution into their personal practice. This study evaluates surgeons' gloving practices and hepatitis status. Methods: A questionnaire was sent to all consultant surgeons and residents in the surgical specialties in the Capital Health region, University of Alberta. A double mail-out design was used. A second questionnaire, containing information on safety issues, was sent to the general surgeons (consultants and residents) who did not double glove to ascertain whether this information would change their practice. Results: In all, 268 surgeons and residents were sent the original questionnaire; 170 replied (63.4% response rate.) Fifty-seven percent of the respondents do not double glove (none of the urologists double glove versus 87% of orthopedic surgeons). The most common reason sited was a decrease in manual dexterity (46%). Ninety-seven percent of respondents are immunized for hepatitis B with 53% having had their titres recently checked. Thirty-seven general surgeons received the evidence on safety issues but only 9 (23%) of them would change their practice as a result of this information. Conclusions: The majority of surgeons and residents do not double glove. Even when provided with good evidence of efficacy, few surgeons contemplate adopting safety techniques.
Abdominal Panniculectomy After Bariatric Surgery: An Unmet Need in the Bariatric Population
Bariatric Surgical Practice and Patient Care, 2019
Introduction: Panniculectomies are performed relatively infrequently despite demand for this proc... more Introduction: Panniculectomies are performed relatively infrequently despite demand for this procedure among bariatric surgery patients. Materials and Methods: In this multicomponent study, a surve...
Canadian Journal of Surgery, 2019
Background: Bariatric surgery has been shown to induce type 2 diabetes mellitus (T2DM) remission ... more Background: Bariatric surgery has been shown to induce type 2 diabetes mellitus (T2DM) remission in severely obese patients. After laparoscopic Roux-en-Y gastric bypass (LRYGB), diabetes remission occurs early and independently of weight loss. Previous research has identified preoperative factors for remission, such as duration of diabetes and HbA 1c. Understanding factors that predict diabetes remission can help to select patients who will benefit most from bariatric surgery. Methods: We retrospectively reviewed all T2DM patients who underwent laparoscopic sleeve gastrectomy (LSG) or LRYGB between January 2008 and July 2014. The primary outcome was diabetes remission, defined as the absence of hypoglycemic medications, fasting blood glucose < 7.0 mmol/L and HbA 1c < 6.5%. Data were analyzed using multivariable logistic regression analysis to identify predictive factors of diabetes remission. Results: We included 207 patients in this analysis; 84 (40.6%) had LSG and 123 (59.4%) had LRYGB. Half of the patients (49.8%) achieved diabetes remission at 1 year. Multivariable logistic analysis showed that LRYGB had higher odds of diabetes remission than LSG (odds ratio [OR] 6.58, 95% confidence interval [CI] 2.79-15.50, p < 0.001). Shorter duration of diabetes (OR 0.91, 95% CI 0.83-0.99, p = 0.032) and the absence of long-acting insulin (OR 0.0011, 95% CI < 0.000-0.236, p = 0.013) predicted remission. Conclusion: Type of bariatric procedure (LRYGB v. LSG), shorter duration of diabetes and the absence of long-acting insulin were independent predictors of diabetes remission after bariatric surgery. Contexte : Il a été démontré que la chirurgie bariatrique provoque une rémission du diabète de type 2 chez les patients gravement obèses. Après la dérivation gastrique Roux-en-Y (DGRY) par laparoscopie, la rémission du diabète se produit tôt et indépendamment de la perte de poids. Des recherches antérieures ont identifié des facteurs préopératoires de rémission, notamment la durée du diabète et l'HbA 1c. Comprendre les facteurs prédictifs de la rémission du diabète peut aider à sélectionner les patients qui bénéficieront le plus de la chirurgie bariatrique. Méthodes : Nous avons examiné rétrospectivement les dossiers de tous les patients atteints de diabète de type 2 qui ont subi par laparoscopie une gastrectomie en manchon (GM) ou une DGRY entre janvier 2008 et juillet 2014. Le principal résultat a été la rémission du diabète, définie comme l'absence de médicaments hypoglycémiques, la glycémie à jeun < 7,0 mmol/L et l'HbA 1c < 6,5 %. Les données ont été soumises à une analyse de régression logistique multiple pour déterminer les facteurs prédictifs de la rémission du diabète. Résultats : Nous avons inclus 207 patients dans cette analyse; 84 (40,6 %) ont subi une GM et 123 (59,4 %), une DGRY. La moitié des patients (49,8 %) ont obtenu une rémission du diabète à 1 an. L'analyse logistique multiple a montré que la DGRY s'accompagnait de probabilités plus élevées de rémission du diabète que la GM (rapport de cotes [RC] 6,58; intervalle de confiance [IC] de 95 %, 2,79-15,50, p < 0,001). La durée plus courte du diabète (RC 0,91; IC de 95 %, 0,83-0,99, p = 0,032) et absence d'insuline à action prolongée (RC 0,0011; IC de 95 % < 0,000-0,236, p = 0,013) étaient prédicteurs de rémission. Conclusion : Le type d'intervention bariatrique (DGRY c. MG), la durée plus courte du diabète et l'absence d'insuline à action prolongée étaient des prédicteurs indépendants de la rémission du diabète après une chirurgie bariatrique.
Canadian journal of gastroenterology & hepatology, 2016
Nonalcoholic fatty liver disease is becoming one of the most common causes of liver disease in th... more Nonalcoholic fatty liver disease is becoming one of the most common causes of liver disease in the western world. The most significant risk factors are obesity and the metabolic syndrome for which bariatric surgery has been shown to be an effective treatment. However, the effects of bariatric surgery on nonalcoholic fatty liver disease, specifically liver fibrosis and cirrhosis, are not well established. We review published bariatric surgery outcomes with respect to nonalcoholic liver disease. On the basis of this review we suggest that bariatric surgery may provide a viable treatment option for the treatment of nonalcoholic fatty liver disease, including patients with fibrosis and compensated cirrhosis, and that this topic should be a target of future investigation.
Canadian Journal of Gastroenterology and Hepatology, 2015
This 2014 roundtable discussion, hosted by the Canadian Association of General Surgeons, brought ... more This 2014 roundtable discussion, hosted by the Canadian Association of General Surgeons, brought together general surgeons and gastroenterologists with expertise in endoscopy from across Canada to discuss the state of endoscopy in Canada. The focus of the roundtable was the evaluation of the competence of general surgeons at endoscopy, reviewing quality assurance parameters for high-quality endoscopy, measuring and assessing surgical resident preparedness for endoscopy practice, evaluating credentialing programs for the endosuite and predicting the future of endoscopic services in Canada. The roundtable noted several important observations. There exist inadequacies in both resident training and the assessment of competency in endoscopy. From these observations, several collaborative recommendations were then stated. These included the need for a formal and standardized system of both accreditation and training endoscopists.
Canadian journal of surgery. Journal canadien de chirurgie
Open cholecystectomy: muscle splitting versus muscle dividing incision: a randomized study
Journal of the Royal College of Surgeons of Edinburgh, 1995
While laparoscopic cholecystectomy has become the standard procedure for symptomatic gallstones, ... more While laparoscopic cholecystectomy has become the standard procedure for symptomatic gallstones, it is likely that 10% of patients will require an open cholecystectomy whether owing to contraindications to the laparoscopic approach or because conversion to the open technique became necessary following laparoscopy. Although the trend towards smaller open cholecystectomy incisions has led to a reduced hospital stay, much of the postoperative morbidity can be ascribed to wound pain. Muscle splitting incisions tend to be less painful than muscle dividing incisions. This randomized consecutive study of elective and emergent open cholecystectomies compared a muscle splitting incision with the traditional muscle dividing technique. The muscle splitting technique was significantly (P < 0.001) less painful than the muscle dividing method as evaluated by the short form of the McGill pain questionnaire. Similarly, a significantly greater proportion of patients were fully mobile on the first...
Canadian journal of surgery. Journal canadien de chirurgie, 2006
Many North American medical schools have removed didactic surgical teaching from the nonclinical ... more Many North American medical schools have removed didactic surgical teaching from the nonclinical years, and there has been a trend toward shortening surgical clerkships. Of concern is that this policy has led to a decrease in surgical exposure and a diminished interest in students pursuing a surgical career. We aimed to determine the effect of curricular change on practical experiences during surgical clerkship and to evaluate overall practical clinical exposure of students during surgical clerkship. We collected validated experience logbooks completed before (1999-2001) and after (2001-2003) the curriculum change at the University of Alberta and converted them into electronic format. The study analyzed 10 procedures and 5 patient management situations. We assessed numbers of procedures performed and student performance on the Objective Structured Clinical Exam (OSCE) and Multiple-Choice Question (MCQ) examinations before and after the curriculum change. In addition, we completed an...
International Journal of Gastrointestinal Cancer, 2002
Background. Rectal cancer adjuvant and neo-adjuvant therapies are associated with improved surviv... more Background. Rectal cancer adjuvant and neo-adjuvant therapies are associated with improved survival and local control rates. Concerns regarding adverse treatment effects tend to reduce administration in the elderly-the very population this disease affects. Purpose. To determine the extent to which age alters rectal cancer treatment and its outcome. Methods and Materials. Using the population based provincial cancer registry, patients with adenocarcinoma of the rectum diagnosed between 1991 and 1998 were identified. From this cohort, a random subsample of patients seen at the regional cancer center were selected for detailed analysis. Demographic and clinical data between the provincial cohort and the subsample were compared for homogeneity. Log rank tests and Kaplan-Meier survival estimates were carried out on the subsample. Results. The population cohort (n = 1979) and the subsample (n = 259) were similar in age, sex, and treatment distributions. Elderly patients (≥75 yr) made up 23% of the rectal cancer population in Alberta. Age had a highly significant (p = 0.001) impact on whether patients received surgery alone or had surgery plus chemoradiotherapy. This corresponded to a considerable survival advantage for those elderly patients who did receive multimodality therapy (p = 0.008). Conclusion. The advantage of multimodality therapy in rectal cancer is confirmed in this populationbased study. Although a significant number of elderly patients are fit enough to tolerate major surgery they are being denied adjuvant therapies, presumably on the basis of potentially high treatment-related complication rates, with a subsequent reduction in survival. Strategies must be developed to ensure that maximum treatment benefit is obtained without increased harm in the elderly rectal cancer patient.
Best Practice & Research Clinical Endocrinology & Metabolism, 2013
Complications of Splenectomy
The American Journal of Medicine, 2008
Surgical removal of the spleen, splenectomy, is a procedure that has significantly decreased in f... more Surgical removal of the spleen, splenectomy, is a procedure that has significantly decreased in frequency as our understanding of the infectious complications of the asplenic state increased. The full spectrum and details of splenic function, however, have yet to be fully outlined. As a result, our comprehension of the long-term consequences of splenectomy remains incomplete. We review the evidence relating to the effects of splenectomy on infection, malignancy, thrombosis, and transplantation. Perhaps the best-defined and most widely understood complication of splenectomy is the asplenic patient&#39;s susceptibility to infection. In response to this concern, novel techniques have emerged to attempt to preserve splenic function in those patients for whom surgical therapy of the spleen is necessary. The efficacy of these techniques in preserving splenic function and staving off the complications associated with splenectomy is also reviewed in this article.
Canadian journal of surgery. Journal canadien de chirurgie, 2012
At its 2009 annual symposium, chaired by Dr. William (Bill) Pollett, the Canadian Association of ... more At its 2009 annual symposium, chaired by Dr. William (Bill) Pollett, the Canadian Association of University Surgeons brought together speakers with expertise in surgery and medical education to discuss the role of surgical simulation for improving surgical training and safety. Dr. Daniel Jones, of Harvard University and the 2009 Charles Tator Lecturer, highlighted how simulation has been used to teach advanced laparoscopic surgery. He also outlined how the American College of Surgeons is moving toward competency assessments as a requirement before surgeons are permitted to perform laparoscopic surgery on patients. Dr. Teodor Grantcharov, from the University of Toronto, highlighted the role of virtual reality simulators in laparoscopic surgery as well as box trainers. Dr. Peter Brindley from the University of Alberta, although a strong proponent of simulation, cautioned against an overzealous adoption without addressing its current limitations. He also emphasized simulation's val...
Canadian journal of surgery. Journal canadien de chirurgie
Many North American medical schools have removed didactic surgical teaching from the nonclinical ... more Many North American medical schools have removed didactic surgical teaching from the nonclinical years, and there has been a trend toward shortening surgical clerkships. Of concern is that this policy has led to a decrease in surgical exposure and a diminished interest in students pursuing a surgical career. We aimed to determine the effect of curricular change on practical experiences during surgical clerkship and to evaluate overall practical clinical exposure of students during surgical clerkship. We collected validated experience logbooks completed before (1999-2001) and after (2001-2003) the curriculum change at the University of Alberta and converted them into electronic format. The study analyzed 10 procedures and 5 patient management situations. We assessed numbers of procedures performed and student performance on the Objective Structured Clinical Exam (OSCE) and Multiple-Choice Question (MCQ) examinations before and after the curriculum change. In addition, we completed an...
Canadian journal of surgery, Jun 1, 2017
A comparison of revisional and primary bariatric surgery Background: Revisional surgery is an imp... more A comparison of revisional and primary bariatric surgery Background: Revisional surgery is an important component of addressing weight regain and complications following primary bariatric surgery. Owing to provincial need and the complexity of this patient population, a specialized multidisciplinary revision clinic was developed. We sought to characterize patients who undergo revision surgery and compare their outcomes with primary bariatric surgery clinic data. Methods: We completed a retrospective chart review of bariatric revision clinic patients compared with primary bariatric surgery patients from December 2009 to June 2014. Results: We reviewed the charts of 2769 primary bariatric clinic patients, 886 of whom had bariatric surgery, and 534 revision bariatric clinic patients, 83 of whom had revision surgery. Fewer revision clinic patients underwent surgery than primary clinic patients (22% v. 32%). The mean preoperative body mass index (BMI) was 44.7 ± 9.5 in revision patients compared with 45.7 ± 7.6 in primary bariatric surgery patients. Most revision patients had a prior vertical banded gastroplasty (VBG; 48%) or a laparoscopic adjustable gastric band (LAGB; 24%). Bands were removed in 36% of all LAGB patients presenting to clinic. Of the 134 procedures performed in the revision clinic, 83 were bariatric weight loss surgeries, and 51 were band removals. Revision clinic patients experienced a significant decrease in BMI (from 44.7 ± 9.5 to 33.8 ± 7.5, p < 0.001); their BMI at 12-month follow-up was similar to that of primary clinic patients (34.5 ± 7.0, p = 0.7). Complications were significantly more frequent in revision patients than primary patients (41% v. 15%, p < 0.001). Conclusion: A bariatric revision clinic manages a wide variety of complex patients distinct from those seen in a primary clinic. Operative candidates at the revision clinic are chosen based on favourable medical, anatomic and psychosocial factors, keeping in mind the resource constraints of a public health care system. Contexte : La chirurgie de révision est une intervention importante lors d'une reprise de poids ou lors de complications à la suite d'une chirurgie bariatrique primaire. Compte tenu des besoins provinciaux et de la complexité de cette population de patients, une clinique de révision multidisciplinaire spécialisée a été créée. Nous avons voulu caractériser les patients qui subissent une chirurgie de révision et comparer leurs résultats aux données de la clinique de chirurgie bariatrique primaire. Méthodes : Nous avons procédé à un examen rétrospectif des dossiers des patients de la clinique de révision bariatrique par rapport aux patients ayant subi une chirurgie bariatrique primaire entre décembre 2009 et juin 2014. Résultats : Nous avons examiné les dossiers de 2769 patients de la clinique bariatrique primaire, dont 886 avaient subi une chirurgie bariatrique, et 534 patients de la clinique de révision, dont 83 avaient subi une chirurgie de révision. Un moins grand nombre de patients de la clinique de révision ont subi une chirurgie comparativement aux patients de la clinique primaire (22 % c. 32 %). L'indice de masse corporelle (IMC) préopératoire moyen était de 44,7 ± 9,5 chez les patients de la clinique de révision, contre 45,7 ± 7,6 chez les patients ayant subi la chirurgie bari atrique primaire. La plupart des patients de la clinique de révision avaient déjà subi une gastroplastie verticale (48 %) ou une pose d'anneau gastrique ajustable par voie laparoscopique (24 %). Les anneaux gastriques ont été retirés chez 36 % de tous les patients de ce dernier groupe s'étant présentés à la clinique. Parmi les 134 interventions effectuées à la clinique de révision, 83 étaient des chirurgies bariatriques (pour perte de poids) et 51 concernaient des retraits d'anneaux. Les patients de la clinique de révision ont obtenu une diminution significative de leur IMC (de 44,7 ± 9,5 à
Uploads
Papers by Christopher Gara