Original Title: Pertinence et indications de transmission des prélèvements chirurgicaux au laboratoire d’anatomopathologie L’oto-rhino-laryngologie et la chirurgie buccale, maxillo et cervico-faciale

Authors' objectives: Section 59 of the 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 fifth report, in a series of six, concerns specimens from otolaryngology and oral, maxillofacial and head and neck 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 examinations’ 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 (#2: CONDITIONS FOR SUBMITTING specimens for an anatomopathological examination): • Several learned societies, including the College of American Pathologists, 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; • Practice does not appear to be harmonized across Québec. Some public institutions in the health and social services network have already put in place a selective submission policy for certain surgical specimens, and others have not (#3: PROFESSIONAL PRACTICE of physicians who take specimens): • There are appropriate ways other than submitting a specimen to the anatomic pathology laboratory to confirm that a specimen was taken (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 taken 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 and to dental surgeons practicing in public institutions. (#4: CLINICAL UTILITY of anatomopathological examinations of specimens from otolaryngology and oral, maxillofacial and head and neck surgery): • For 40 surgical specimens initially identified, the risk of a clinically significant incidental finding was considered low for 21 specimens; 20 were based on the literature reviewed and the current selective submission lists identified, and 1 was proposed by the stakeholders consulted; • Four surgical specimens were excluded from the selective-submission list because of the risk of an incidental finding on anatomopathological examination, the contribution of gross or microscopic findings to the prognosis, or medicolegal issues; • Ten specimens for which the risk of a clinically significant incidental finding was considered low were specific to otolaryngology and oral, maxillofacial and head and neck surgery; (#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 otolaryngology and oral, maxillofacial and head and neck surgery, the reduction in the number of routine submissions to anatomic pathology laboratories for some of these high-volume specimens (e.g., tonsils from individuals under 18 years of age) should result in a 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 otolaryngology and oral, maxillofacial and head and neck surgery, 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 when they were developed, 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 OTOLARYNGOLOGY AND ORAL, MAXILLOFACIAL AND HEAD AND NECK SURGERY After reviewing the information 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. OTOLARYNGOLOGY AND HEAD AND NECK SURGERY  Adenoids in a person under 18 years of age  Tonsils in a person under 18 years of age  Otologic reconstruction and ossicle from a middle ear stapedectomy  Tissue from a supraglottoplasty  Tissue from a turbinoplasty  Tissue from a tympanoplasty of normal clinical appearance ORAL AND MAXILLOFACIAL SURGERY  Dental appliance and restoration  Mandibular condyle head and surrounding tissue if resected because of arthrosis or ankylosis  Extracted tooth and associated tissue of normal clinical appearance  Bone, ligament or muscle fragment from reconstructive surgery  Submandibular or donor site liposuction  Rib portion harvested for bone or cartilage grafting from a patient with no history of cancer  Specimen from preprosthetic surgery, e.g., hyperplastic ridge, tuberosity (from a tuberoplasty), oral exostosis, torus SPECIMENS COMMON TO DIFFERENT SUGICAL SPECIALTIES  Blood clot from a hematoma or thrombus  Foreign bodies  Scars of normal appearance  Scars from recent burns or from non-neoplastic surgery  Implants and medical devices removed during a surgical procedure  Tissue removed during debridement for a known cause  Tissue resulting from a cosmetic (or reconstructive) correction, e.g., dog ears, rhinoplasty, scar revision, septoplasty, otoplasty, osteotomy, cleft lip and palate (excluding rhinophyma tissue)  Excess subcutaneous tissue removed for gaining surgical access

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 otolaryngology and oral, maxillofacial and head and neck surgery that could be selectively submitted to the anatomic pathology laboratory were developed through a 3-round simplified Delphi consultation process. This was carried out with the advisory committee’s members using data and recommendations information 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