Original Title: Avis - Pertinence et indications de transmission des prélèvements chirurgicaux au laboratoire d’anatomopathologie : la chirurgie générale, la plastie et la dermatologie

Authors' objectives: Since the publication of the Organization and Management of Institutions Regulation (C.Q.L.R., chapter S-5, r. 5)1 in 1984, section 59 has generally been interpreted in Québec’s clinical circles to mean that all surgical specimens must be sent to the anatomic pathology laboratory for analysis. This regulatory provision has, for many years, resulted in a large volume of specimens being submitted and analyzed. It is estimated that a significant proportion of these submissions may not be necessary. To promote optimal utilization of anatomic pathology resources and ensure consistency between institutions, the Ministère de la Santé et des Services sociaux asked the Institut national d’excellence en santé et en services sociaux (INESSS) to make recommendations to guide clinicians in their decision to submit or not submit certain surgical specimens to the anatomic pathology laboratory, based on the anatomical region, the domain of surgical expertise concerned, and the relevance of an anatomopathological examination. To this end, the project has been divided into six parts: orthopedic surgery and neurosurgery, general surgery, plastic surgery and dermatology (part A); the general surgery subspecialities (part B); obstetrics/gynecology and urology; cardiovascular and thoracic surgery; otolaryngology and maxillofacial and cervicofacial surgery; and ophthalmology. The present report deals with surgical specimens arising from general surgery, plastic surgery and dermatology.

Authors' results and conclusions: RESULTS: The literature review permitted the identification of studies that deal primarily with the anatomopathological analysis of gallbladders and inguinal hernia sacs. Based on the scientific literature, there is a low risk of not detecting gallbladder cancer (< 0.5%) when selectively submitting specimens to the anatomic pathology laboratory only when there is an abnormality on gross examination, since this cancer is usually detected pre- or intraoperatively. However, the experts consulted were of the opinion that gallbladders from cholecystectomies should be systematically sent to the anatomic pathology laboratory due to the seriousness of the disease, which is associated with a poor prognosis. In the case of hernia sacs, the identification of a structure of the reproductive system (epididymis or vas deferens) or cancer on anatomopathological examination is considered a significant finding for clinical management; its frequency varies from 0 to 0.88%, depending on the study. Only one study reported unexpected cases of cancer (in 0.06%). Identifying epididymal or vas deferens tissue in specimens from an inguinal hernia repair in a pediatric patient would have little impact on their immediate management. The clinical course of action is usually to defer treatment in cases where a consequence would occur late (e.g., azoospermia). Seven studies on the procedures for submitting specimens to the anatomic pathology laboratory from general surgery, plastic surgery and dermatology to anatomic pathology were identified. Studies regarding skin lesion specimens suggest that there is a low risk of missing malignancy when not performing a histopathological analysis of acrochordons, epidermoid cysts, sebaceous cysts or benign hand lesions. However, only one study was identified for each of these specimen types. One study of subcutaneous lesion excision, in which most of the lesions were lipomas, showed a fortuitous malignancy discovery rate of 2.4% for this type of lesion. CONCLUSIONS: The analysis and integration of the data from the scientific literature, the learned society guidelines and positions, and the perspectives of various stakeholders have enabled INESSS to make recommendations concerning the selective submission of certain surgical specimens to the anatomic pathology laboratory. These recommendations should contribute to more judicious utilization of anatomic pathology resources. However, the changes to practice that might result from them will depend on the dissemination and implementation of the recommendations in Québec’s health-care facilities. A gradual implementation with the councils of physicians, the directors of professional services, the OPTILAB co-directors and other bodies responsible for the quality of care acting in concert will be needed to facilitate the changes and ensure optimal management of risk and of the quality of medical acts.

Authors' methods: To fulfill the mandate, a systematic review was carried out in the scientific literature and using publications presenting or containing positions, recommendations or guidance on the subject. In addition, contextual information and the perspectives of various stakeholders were gathered to document perceptions of and level of acceptability associated with the selective submission of certain surgical specimens and materials to the anatomic pathology laboratory, and to determine the potential organizational, clinical, ethical and legal issues. To gather different perspectives, INESSS created an advisory committee consisting of general surgeons, a dermatologist, a family physician and anatomic pathologists. In addition, electronic surveys were sent to the directors of professional services and OPTILAB co-directors (a clinical laboratory reorganization project) to obtain information on surgical specimen submission practices and anatomic pathology resource utilization in Québec’s health-care facilities. The Canadian Medical Protective Association was consulted to validate certain medicolegal issues potentially associated with a change in the procedures for submitting surgical specimens. Information on the impact of selective submission of certain surgical specimens on billing and auditing processes was obtained from the Régie de l’assurance maladie du Québec. The recommendations concerning general surgery, plastic surgery and dermatology specimens that could be submitted to the anatomic pathology laboratory according to a selective approach are based on a simplified Delphi consultation process with 4 rounds. This process was carried out with the advisory committee in the light of the data and information from the systematic literature review and from consultations with informants and stakeholders, including the aforementioned Canadian Medical Protective Association and Régie de l’assurance maladie du Québec.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/en/publications/publications/publication/pertinence-et-indications-de-transmission-des-prelevements-chirurgicaux-au-laboratoire-danatomopathologie-la-chirurgie-generale-la-plastie-et-la-dermatologie.html

Year Published: 2021

URL for published report: https://www.inesss.qc.ca/en/publications/publications/publication/pertinence-et-indications-de-transmission-des-prelevements-chirurgicaux-au-laboratoire-danatomopathologie-la-chirurgie-generale-la-plastie-et-la-dermatologie.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec