Original Title: Avis : Pertinence et indications de transmission des prélèvements chirurgicaux au laboratoire d’anatomopathologie - La chirurgie vasculaire, cardiovasculaire et thoracique

Authors' objectives: Section 59 of Organization and Management of Institutions Regulation (C.Q.L.R., chapter S-5, r. 5) has generally been interpreted as meaning that all surgical specimens must be submitted 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. This generates potentially substantial costs and results in suboptimal analysis turnaround times. It is estimated that a significant proportion of these submissions may not be necessary because the anatomopathological examination is unlikely to provide information that would be useful for patient management. To reduce the number of unnecessary requests for an anatomopathological examination and to promote optimal anatomic pathology laboratory resource utilization, the ministère de la Santé et des Services sociaux asked the Institut national d'excellence en santé et en services sociaux (INESSS) to determine which surgical specimens could be considered for selective submission to the anatomic pathology laboratory and to spell out the conditions for submitting them. This fourth report, in a series of six, concerns specimens from vascular, cardiovascular and thoracic surgery.

Authors' results and conclusions: RESULTS: (#1: OVERALL CLINICAL UTILITY): • The decision to submit or not submit surgical specimens to the anatomic pathology laboratory is usually based on clinical suspicion or the examination’s diagnostic or prognostic value; • Changes in knowledge, technology and practice inevitably lead to changes in the clinical relevance of submitting or not submitting some of these specimens; • Because of the nature and purpose of the surgical procedure or of the tissue’s or organ’s characteristics, many specimens removed must be systematically submitted to the anatomic pathology laboratory, while others should not. For some, the value of routine submission to the laboratory may be questioned. The decision should be made on a case-by-case basis according to the available scientific data, the best clinical practice recommendations, the clinical picture and the surgeon’s judgment. (#2: CONDITIONS FOR SUBMITTING SPECIMENS): • Several learned societies, including the College of American Pathologists (CAP), have proposed models for the selective submission of certain surgical specimens to the anatomic pathology laboratory in order to promote the efficient use of its resources; • The lists of specimens that could be selectively submitted for an anatomopathological examination, as proposed in the guidelines reviewed and by certain Québec institutions, differ in terms of the number and type of specimens; (#3: PROFESSIONAL PRACTICE OF PHYSICIANS WHO REMOVE SPECIMENS): • There are appropriate ways other than submitting a specimen to the anatomic pathology laboratory to confirm that a specimen was removed (e.g., nurse confirmation and surgical notes); • The standards for chart- and register-keeping by a physician are set out in regulations. Thus, the surgeon’s surgical notes and surgery report are official documents in which any specimen removed during a surgical procedure must be documented and included in the patient's chart. The surgery report should be written or dictated within 24 hours of the procedure. This practice applies to physicians practicing in both the public and private institutions in the health and social services system. (#4: CLINICAL UTILITY of anatomopathological examinations of specimens from vascular, cardiovascular and thoracic surgery): • For 33 surgical specimens initially identified, and after consolidation that reduced this list to 26, the risk of a clinically significant incidental finding was considered low for 18 of the 26 specimens. Sixteen were based on the literature reviewed and the current submission lists identified, and 2 were based solely on the perspectives of the stakeholders consulted; • The surgical context was clarified for two surgical specimens on one of the selective submission lists identified; (#5: POTENTIAL SAVINGS associated with a change in practice in the submission of specimens for an anatomopathological examination): • The selective-submission recommendations made by certain learned societies and organizations have led to a reduction in the workload associated with the analysis of specimens of limited or no clinical value; • In vascular, cardiovascular and thoracic surgery, the reduction in the number of routine submissions to the anatomic pathology laboratory of some of these high-volume specimens (e.g., endarterectomy material) should result in the faster completion of anatomopathological examinations whose results are clinically crucial, such as in oncology. CONCLUSION: Upon the completion of this work, the selective submission list for specimens from vascular, cardiovascular and thoracic surgery that was drawn up, for which the level of risk for the patient was considered low and the anatomopathological examination unlikely to provide any useful information for patient management, should contribute to more judicious anatomic pathology laboratory resource utilization. Gradual implementation involving consultation between the Council of physicians, dentists and pharmacists, the directors of professional services, the OPTILAB co-directors and other bodies responsible for the quality of care will be needed to facilitate the changes and ensure optimal risk and medical procedure quality management. Since the recommendations are based on the scientific knowledge available at this time, it is possible that they will be modified in light of future scientific advances that might make the anatomopathological examination of certain surgical specimens clinically useful. For this reason, the advisability of updating these recommendations will be assessed in four years, that is, in 2026.

Authors' recommendations: SELECTIVE SUBMISSION RECOMMENDATIONS SPECIFIC TO VASCULAR, CARDIOVASCULAR AND THORACIC SURGERY After reviewing all the data gathered, INESSS recommends that the following surgical specimens be submitted to the anatomic pathology laboratory on a selective basis for analysis, this throughout Québec. ! This list is not a substitute for the clinician’s judgment. VASCULAR SURGERY  Major or minor lower-limb amputation specimens in the context of peripheral vascular disease  Prosthesis, endoprosthesis or graft removed during vascular surgery  Venous specimens removed during a saphenectomy or phlebectomy CARDIOVASCULAR SURGERY  Residual donor and recipient tissue during a heart transplant  Residual cadaveric donor tissue during a valve replacement  Coronary ostia CHEST SURGERY  Specimens removed during hiatal hernia surgery  Mediastinal fat specimens removed for better surgical access  Sternal debridement specimens (except when looking for osteomyelitis)  Residual donor and recipient tissue from a lung transplant (except in cases of pneumoreduction) SPECIMENS COMMON TO DIFFERENT SURGICAL SPECIALTIES  Endarterectomy material (atherosclerotic plaque)  Traumatic or postoperative hematoma  Wall thrombus removed during an abdominal aortic aneurysm repair  Abdominal aortic or aortoiliac aneurysm wall specimens  Arterial or venous autograft segments not used in a revascularization procedure (e.g., saphenous vein, radial artery or mammary artery)  Rib segments removed for better surgical access (normal ribs with no history of pathology)  Foreign bodies (unless forensic documentation is required)  Implants, devices and medical equipment (with the exception of prosthetic heart valves) removed during a cardiovascular or thoracic procedure (unless forensic documentation is required) - Examples of implants and prostheses included in the wording: intravascular catheters or probes, removed surgical endoprostheses (stents and meshes), defibrillator, pacemaker, cardiac pacing lead, intracardiac implants, drainage tube, hemostats, therapeutic radioactive sources, Nuss bar.

Authors' methods: Using preestablished criteria, we conducted a systematic review of the scientific literature and of publications presenting positions, recommendations and guidance from learned societies and other organizations. In addition, contextual information and the perspectives of various stakeholders were gathered by an advisory committee consisting of individuals representing the various medical specialties concerned and by a monitoring committee consisting mainly of representatives from the professional orders and associations of the medical specialists concerned, and from different bodies, including the Régie de l'assurance maladie du Québec and the ministère de la Santé et des Services sociaux. These consultations enabled us to gather experiential knowledge, to document perceptions and the level of acceptability concerning the selective or non-selective submission of certain surgical materials and specimens to the anatomic pathology laboratory, and to determine the potential organizational, clinical, economic, ethical and legal issues. The recommendations concerning surgical specimens from vascular, cardiovascular and thoracic surgery that could be selectively submitted to the anatomic pathology laboratory were developed through a 2-round simplified Delphi consultation process. This was carried out with the advisory committee’s members using data and recommendations extracted from the systematic literature search. The monitoring committee’s members were then asked to assess the list of samples that could be selectively submitted and to assess the applicability, acceptability and potential impact of implementing the recommendations.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/pertinence-et-indications-de-transmission-selective-de-prelevements-chirurgicaux-au-laboratoire-danatomopathologie.html

Year Published: 2022

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/pertinence-et-indications-de-transmission-selective-de-prelevements-chirurgicaux-au-laboratoire-danatomopathologie.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