The Association of Intra-Abdominal Adhesions with Peritoneal Dialysis Catheter-Related Complications

BACKGROUND

This study investigated the association of intra-abdominal adhesions with the risk of peritoneal dialysis (PD) catheter complications.

METHODS

Individuals undergoing laparoscopic PD catheter insertion were prospectively enrolled from eight centers in Canada and the United States. Patients were grouped based on the presence of adhesions observed during catheter insertion. The primary outcome was the composite of PD never starting, termination of PD, or the need for an invasive procedure caused by flow restriction or abdominal pain.

RESULTS

Seven hundred and fifty-eight individuals were enrolled, of whom 201 (27%) had adhesions during laparoscopic PD catheter insertion. The risk of the primary outcome occurred in 35 (17%) in the adhesion group compared with 58 (10%) in the no adhesion group (adjusted HR, 1.64; 95% confidence interval [CI], 1.05 to 2.55) within 6 months of insertion. Lower abdominal or pelvic adhesions had an adjusted HR of 1.80 (95% CI, 1.09 to 2.98) compared with the no adhesion group. Invasive procedures were required in 26 (13%) and 47 (8%) of the adhesion and no adhesion groups, respectively (unadjusted HR, 1.60: 95% CI, 1.04 to 2.47) within 6 months of insertion. The adjusted odds ratio for adhesions for women was 1.65 (95% CI, 1.12 to 2.41), for body mass index per 5 kg/m 2 was 1.16 (95% CI, 1.003 to 1.34), and for prior abdominal surgery was 8.34 (95% CI, 5.5 to 12.34). Common abnormalities found during invasive procedures included PD catheter tip migration, occlusion of the lumen with fibrin, omental wrapping, adherence to the bowel, and the development of new adhesions.

CONCLUSIONS

People with intra-abdominal adhesions undergoing PD catheter insertion were at higher risk for abdominal pain or flow restriction preventing PD from starting, PD termination, or requiring an invasive procedure. However, most patients, with or without adhesions, did not experience complications, and most complications did not lead to the termination of PD therapy.

Postoperative protocols for older adults undergoing emergency surgery: a scoping review

BACKGROUND

As the population of older adults expands, it is becoming increasingly crucial to develop perioperative protocols to meet their physiologic, functional, and cognitive demands after emergency surgery. We sought to identify protocols that improve the disposition, length of stay, and overall health outcomes of older adults undergoing emergency intracavitary, noncardiac surgery.

METHODS

Embase, Cochrane, and MEDLINE databases were searched, and results were deduplicated and uploaded to Covidence. We reviewed studies for postoperative interventions that reduced delirium, maintained functional status, and reduced length of stay in older patients undergoing emergency surgery. We included studies involving patients aged 65 years and older undergoing emergency intracavitary, noncardiac surgeries. Abstracts and full texts were reviewed by 2 reviewers. Data were extracted on the postoperative interventions used and the resulting patient outcomes.

RESULTS

We included 6 studies, which involved patients undergoing emergency general, urology, and vascular surgery. Interventions included a multidisciplinary approach, early involvement of a geriatrician or hospitalist, targeted geriatric-led ward rounds, unique postoperative order sets, and volunteer-driven activities. Standard care included early removal of lines, early mobility, optimal hydration, and medication review. These interventions were associated with decreased length of stay, decreased postoperative complications, and increased likelihood of disposition to home and previous functional status. Frailty was correlated with worse outcomes.

CONCLUSION

Through multidisciplinary interventions, a successful postoperative protocol for older patients undergoing emergency surgery is helpful for improving patient outcomes. The implications of these findings will help guide our own quality-improvement initiative to improve these outcomes in this patient population at our institution.

Satisfaction and attrition in Canadian surgical training program leadership: a survey of program directors

BACKGROUND

Surgical program directors (PDs) play an integral role in the well-being and success of postgraduate trainees. Although studies about medical specialties have documented factors contributing to PD burnout, early attrition rates and contributory factors among surgical PDs have not yet been described. We aimed to evaluate Canadian surgical PD satisfaction, stressors in the role and areas institutions could target to improve PD support.

METHODS

We administered a cross-sectional survey of postgraduate Canadian surgical PDs from all Royal College of Physicians and Surgeons of Canada accredited surgical specialties. Domains we assessed included PD demographics and compensation, availability of administrative support, satisfaction with the PD role and factors contributing to PD challenges and burnout.

RESULTS

Sixty percent of eligible surgical PDs (81 out of 134) from all 12 surgical specialties responded to the survey. We found significant heterogeneity in PD tenure, compensation models and available administrative support. All respondents reported exceeding their weekly protected time for the PD position, and 66% received less than 0.8 full-time equivalent of administrative support. One-third of respondents were satisfied with overall compensation, whereas 43% were unhappy with compensatory models. Most respondents (70%) enjoyed many aspects of the PD role, including relationships with trainees and shaping the education of future surgeons. Significant stressors included insufficient administrative support, complexities in resident remediation and inadequate compensation, which contributed to 37% of PDs having considered leaving the post prematurely.

INTERPRETATION

Most surgical PDs enjoyed the role. However, intersecting factors such as disproportionate time demands, lack of administrative support and inadequate compensation for the role contributed to significant stress and risk of early attrition.

Water-soluble contrast in the management of adhesive small-bowel obstruction: a Canadian centre’s experience with guideline development and implementation

Background:

Orally administered water-soluble contrast (WSC) can track resolution of small-bowel obstruction (SBO), but no universal pathway for its use exists. We developed and implemented an evidence-based guideline for the use of WSC in the management of adhesive SBO, to be implemented across hospitals affiliated with the University of Toronto.

Methods:

We performed a systematic review and created a clinical practice guideline for WSC use in the management of adhesive SBO. The guideline was approved through consensus by an expert panel and implemented in 2018. We performed a prospective cohort study of guideline implementation at 1 pilot site (a large academic tertiary care centre), facilitated by the centre’s acute care general surgery service. Primary outcomes included compliance with the guideline and hospital length of stay (LOS). Secondary outcomes included rates of failure of nonoperative management, morbidity, mortality and readmission for recurrence of SBO within 1 year. Patients with adhesive SBO admitted in 2016 served as a control cohort.

Results:

We analyzed the data for 152 patients with adhesive SBO admitted to the centre, 65 in 2016 (historical cohort), 56 in January–June 2018 (transitional cohort) and 31 in July–December 2018 (implementation cohort). There was a significant increase in compliance with the WSC protocol in 2018, with the proportion of patients receiving WSC increasing from 45% (n = 25) in the transitional cohort to 71% (n = 22) in the implementation cohort (p < 0.001). The median LOS did not differ across the cohorts (p = 0.06). There was a significantly lower readmission rate in the transitional and implementation cohorts (13 [23%] and 9 [29%], respectively) than in the historical cohort (29 [45%]) (p = 0.04). Among patients assigned to nonoperative management initially, a significantly higher proportion of those who received WSC than those who did not receive WSC went on to undergo surgery (14.6% v. 3.6%, p = 0.01), with no difference in median time to surgery (p = 0.2).

Conclusion:

An evidence-based guideline for WSC use in SBO management was successfully developed and implemented; no difference in LOS or time to surgery was seen after implementation, but rates of immediate operation increased and readmission rates decreased. Our experience shows that implementation of an evidence-based clinical practice guideline is feasible through multidisciplinary efforts and coordination.

Malignant Bowel Obstruction Management Over Time: Are We Doing Anything New? A Current Narrative Review

INTRODUCTION

Malignant bowel obstruction from peritoneal carcinomatosis affects a significant proportion of luminal gastrointestinal and ovarian oncology patients, and portends poor long-term survival. The management approach for these patients includes a range of medical therapies and surgical options; however, how to select an optimal treatment strategy remains enigmatic. The goal of this narrative review was to summarize the latest evidence around multimodal malignant bowel obstruction treatment and to establish if and where progress has been made.

METHODS

A targeted literature search examining articles focused on the management of malignant bowel obstruction from peritoneal carcinomatosis was performed. Following data extraction, a narrative review approach was selected to describe evidence and guidelines for surgical prognostic factors, imaging, tube decompression, medical management, nutrition, and quality of life.

RESULTS

Outcomes in the literature to date are summarized for various malignant bowel obstruction treatment strategies, including surgical and non-surgical approaches, as well as a discussion of the role of total parenteral nutrition and chemotherapy in holistic malignant bowel obstruction management.

CONCLUSION

There has been little change in survival outcomes in malignant bowel obstruction in over more than a decade and there remains a paucity of high-level evidence to direct treatment decision making. Healthcare providers treating patients with malignant bowel obstruction should work to establish consensus guidelines, where feasible, to support medical providers in ensuring compassionate care during this often terminal event for this unique patient group.

Quality of Colon Cancer Care in Patients Undergoing Emergency Surgery

Thirty percent of colon cancer diagnoses occur following emergency presentations, often with bowel obstruction or perforation requiring urgent surgery. We sought to compare cancer care quality between patients receiving emergency versus elective surgery. We conducted an institutional retrospective matched (46 elective:23 emergency; n = 69) case control study. Patients who underwent a colon cancer resection from January 2017 to February 2019 were matched by age, sex, and cancer stage. Data were collected through the National Surgical Quality Improvement Program and chart review. Process outcomes of interest included receipt of cross-sectional imaging, CEA testing, pre-operative cancer diagnosis, pre-operative colonoscopy, margin status, nodal yield, pathology reporting, and oncology referral. No differences were found between elective and emergency groups with respect to demographics, margin status, nodal yield, oncology referral times/rates, or time to pathology reporting. Patients undergoing emergency surgery were less likely to have CEA levels, CT staging, and colonoscopy (p = 0.004, p = 0.017, p < 0.001). Emergency cases were less likely to be approached laparoscopically (p = 0.03), and patients had a longer length of stay (p < 0.001) and 30-day readmission rate (p = 0.01). Patients undergoing emergency surgery receive high quality resections and timely post-operative referrals but receive inferior peri-operative workup. The adoption of a hybrid acute care surgery model including short-interval follow-up with a surgical oncologist or colorectal surgeon may improve the quality of care that patients with colon cancer receive after acute presentations. Surgeons treating patients with colon cancer emergently can improve their care quality by ensuring that appropriate and timely disease evaluation is completed.

Lesional therapies for in-transit melanoma

BACKGROUND AND OBJECTIVES

To describe the outcomes of lesional therapy of in-transit melanoma (ITM) with interleukin-2 (IL-2), diphencyprone (DPCP), combination lesional therapy (IL-2, retinoid, and imiquimod; CLT), and imiquimod.

METHODS

Data was collected for consecutive patients with ITM receiving lesional therapies from 2008 to 2018 in a retrospective review. Included patients did not have metastatic disease at time of starting on lesional therapy and were not on systemic therapy. The primary outcome was complete pathologic response (pCR).

RESULTS

Of 83 patients, 57 (69%) started treatment with IL-2, 10 (12%) with DPCP, 12 (14%) with CLT, and 4 (5%) with imiquimod. pCR was achieved in 34 patients (41%) overall, including 44% starting on IL-2, 20% on DPCP, 58% on CLT, and none on imiquimod (P = .024). With a median follow-up of 45 months, cumulative one-year overall survival was 86%, with the best survival in the CLT group. Forty-eight percent experienced common terminology criteria for adverse events grade 1 or 2 toxicity. A quarter of patients on DPCP discontinued therapy due to toxicity (P = .002).

CONCLUSIONS

IL-2 may be considered for the treatment of ITM with multiple or rapidly developing lesions where there would otherwise be significant morbidity with surgery, given pCR rates and toxicity.

Metastasis to gastrostomy sites from upper aerodigestive tract malignancies: a systematic review and meta-analysis

BACKGROUND AND AIMS

Metastasis to the gastrostomy site in patients with upper aerodigestive tract (UADT) malignancies is a rare but devastating adverse event that has been poorly described. Our aim was to determine the overall incidence and clinicopathologic characteristics observed with development of gastrostomy site metastasis in patients with UADT cancers.

METHODS

This was a systematic review and meta-analysis of 6138 studies retrieved from Medline, EMBASE, CINAHL, and the Cochrane Register after being queried for studies including gastrostomy site metastasis in patients with UADT malignancies.

RESULTS

The final analysis included 121 studies. Pooled analysis showed an overall event rate gastrostomy site metastasis of .5% (95% confidence interval [CI], .4%-.7%). Subgroup analysis showed an event rate of .56% (95% CI, .40%-.79%) with the pull technique and .29% (95% CI, .15%-.55%) with the push technique. Clinicopathologic characteristics observed with gastrostomy site metastasis were late-stage disease (T3/T4) (57.8%), positive lymph node status (51.2%), and no evidence of systemic disease (M0) (62.8%) at initial presentation. The average time from gastrostomy placement to diagnosis of metastasis was 7.78 ± 4.9 months, average tumor size on detection was 4.65 cm (standard deviation, 2.02), and average length of survival was 7.26 months (standard deviation, 6.23).

CONCLUSIONS

Gastrostomy site metastasis is a rare but serious adverse event that occurs at an overall rate of .5%, particularly in patients with advanced-stage disease, and is observed with a very poor prognosis. These findings emphasize a need for clinical practice guidelines to include a regular assessment of the PEG site and highlight the importance of detection and management of gastrostomy site metastasis by the multidisciplinary care oncology team.

Biliary microbiome in pancreatic cancer: alterations with neoadjuvant therapy

BACKGROUND

Neoadjuvant therapy for pancreatic cancer is being employed more commonly. Most of these patients undergo biliary stenting which results in bacterial colonization and more surgical site infections (SSIs). However, the influence of neoadjuvant therapy on the biliary microbiome has not been studied.

METHODS

From 2007 to 2017, patients at our institution who underwent pancreatoduodenectomy (PD) and had operative bile cultures were studied. Patient demographics, stent placement, bile cultures, bacterial sensitivities, SSIs and clinically-relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Patients who underwent neoadjuvant therapy were compared to those who went directly to surgery. Standard statistical analyses were performed.

RESULTS

Eighty-three patients received neoadjuvant therapy while 89 underwent surgery alone. Patients who received neoadjuvant therapy were more likely to have enterococci (45 vs 22%, p < 0.01), and Klebsiella (37 vs 19%, p < 0.01) in their bile. Resistance to cephalosporins was more common in those who received neoadjuvant therapy (76 vs 60%, p < 0.05). Neoadjuvant therapy did not affect the incidence of SSIs or CR-POPFs.

CONCLUSION

The biliary microbiome is altered in patients undergoing pancreatoduodenectomy (PD) after neoadjuvant therapy. Most patients undergoing PD with a biliary stent have microorganisms resistant to cephalosporins. Antibiotic prophylaxis in these patients should cover enterococci and gram-negative bacteria.

Opioid stewardship after emergency laparoscopic general surgery

Background

Opioid administration in postoperative patients has contributed to the opioid crisis by increasing the load of opioids available in the community. Implementation of evidence-based practices is key to optimizing the use of opioids for acute pain control. This study aims to characterize the administration and prescribing practices after emergency laparoscopic general surgery procedures with the goal of identifying areas for improvement.

Methods

A retrospective chart review of 200 patients undergoing emergency laparoscopic appendectomies and cholecystectomies was conducted for a 2-year period at a single institution. Eligible patients were opioid-naïve adults admitted through the emergency department. Opioid administration and discharge prescriptions were converted to oral morphine equivalents (OME), and analyzed and compared with published literature and local guidelines.

Results

Opioid analgesia was provided as needed to 69% of patients in hospital with average dosing of 26.7 OME/day; comparatively, 99.5% of patients received prescriptions for opioids on discharge at an average dosing of 61.7 OME/day. The average dosing in the discharge prescriptions was not correlated with in-hospital needs (Pearson=−0.04; p=0.56); and higher narcotic doses were associated with combination opioid prescriptions compared with separate opioid prescriptions (73.8 (1.90) vs. 50.1 (1.90) OME/day; p<0.01). This difference was driven by the combination medication, Percocet.

Conclusions

In the immediate postoperative period, most patients were managed in hospital with opioid analgesia dosages that fell within guidelines. Nearly all patients were provided with prescriptions for opioids on discharge, these prescriptions both exceeded local guidelines and were not correlated with in-hospital narcotic needs or pain scores.

Level of evidence

Level 3 retrospective cohort study.

Soft tissue sarcoma of the extremity: Characterizing symptom duration and outcomes

BACKGROUND

We sought to investigate how the interval between symptom onset and diagnosis of soft tissue sarcoma (STS) of the extremity was associated with survival.

METHODS

Patients treated for extremity STS years 2006-2015 were stratified by symptom duration: at least two, six or twelve months between symptom onset and diagnosis. Chi-square tests compared patient and tumor-related characteristics based on symptom duration. Survival analysis included Cox regression and Kaplan-Meier estimates.

RESULTS

Of 113 patients included, mean age was 56.7 years, 52.2% were male, and 75.2% were white. Median tumor size was 75 mm, 48.7% were grade 3, and 38.1% were stage I. With symptom duration of either at least 6 or 12 months, a greater proportion of patients who experienced the specified symptom duration had lower grade tumors (p < 0.01 and p = 0.01, respectively) and lower stage disease (p < 0.01 and p = 0.02, respectively) than those who did not. Among all patients, survival estimates were similar between those who experienced a symptom duration of 2 (p = 0.12), 6 (p = 0.18) or 12 (p = 0.61) months and those who did not.

CONCLUSION

Patients with extremity STS who tolerated a longer symptom duration had less advanced disease. Reasons for prolonged symptom duration and methods to address these factors warrant further investigation.

Single-dose testosterone administration increases men's preference for status goods

In modern human cultures where social hierarchies are ubiquitous, people typically signal their hierarchical position through consumption of positional goods-goods that convey one's social position, such as luxury products. Building on animal research and early correlational human studies linking the sex steroid hormone testosterone with hierarchical social interactions, we investigate the influence of testosterone on men's preferences for positional goods. Using a placebo-controlled experiment (N = 243) to measure individuals' desire for status brands and products, we find that administering testosterone increases men's preference for status brands, compared to brands of similar perceived quality but lower perceived status. Furthermore, testosterone increases positive attitudes toward positional goods when they are described as status-enhancing, but not when they are described as power-enhancing or high in quality. Our results provide novel causal evidence for the biological roots of men's preferences for status, bridging decades of animal behavioral studies with contemporary consumer research.

Post-discharge venous thromboembolism prophylaxis for surgical oncology patients

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Background: A number of guidelines have been proposed for prolonged venous thromboembolism (VTE) prophylaxis following hospital discharge for cancer patients undergoing major abdominal or pelvic surgery. However, there is disparity in how closely these guidelines are followed. The purpose of this study was to examine the administration and complications of post-discharge chemical VTE prophylaxis (pdVTE) at an institutional level among surgical oncology patients to help inform policy creation. Methods: A retrospective study at a tertiary referral cancer center was performed. Data was analyzed for patients undergoing surgery in 2015. Chi-square tests were performed. Results: Of 566 colorectal, urologic, and gynecologic surgical oncology procedures performed in 2015, 24% (137) were discharged with a prescription for enoxaparin for pdVTE. An additional 24 patients were already on another form of anticoagulation at the time of discharge. Of the patients discharged on pdVTE, 77% (105) had the prescriptions filled. The compliance rate of those patients was 96% (101). The rate of VTE was 3.5% for all patients. There was a significantly greater rate of VTE amongst patients that received pdVTE (10.4%) compared to those who did not (1.6%) (OR 7.20, CI 2.80-18.46, p < 0.001). For each subspecialty, there was also a significantly greater rate of VTE amongst patients that received pdVTE (p < 0.001). Conclusions: There is a very low rate of pdVTE administration despite current guidelines. Identifying patients who received pdVTE appears to identify patients at high risk for VTE rather than the benefits of pdVTE. Institutional policies regarding prolonged VTE prophylaxis should be implemented to target high-risk patients and to ensure appropriate prescribing practices. [Table: see text]

Practice patterns of molecular profiling in colorectal cancer

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Background: Colorectal cancer (CRC) is a genetically heterogeneous disease. Molecular profiling (MP) using next-generation sequencing is increasingly used to personalize therapy. No guidelines currently exist regarding patient selection and optimal timing. Our goal was to describe our experience at a tertiary cancer center using MP in CRC patients. Methods: This is an IRB-approved, retrospective study in patients with CRC who underwent MP between March 2007 and August 2016. Tissue samples were sent for analysis in the following MP platforms: Foundation One, Caris, and FCCC Targeted Cancer Panel (FTCP), which tests for the 50 most common mutations. Data regarding patient demographics, mutations, and clinical outcomes were analyzed. Kaplan Meier methods were used for survival analysis using SPSS. Results: We evaluated 248 patients with CRC. 60.1% were male and 80.1% were white. The median age was 59.5 years. 66.5% had colon and 33.5% had rectal CA. Initial stages: stage 1 (2.8%), stage 2 (14.1%), stage 3 (22.9%), stage 4 (59.2%). 82.2% were tested via FTCP, 8.9% via Foundation One, and 9.3% via Caris. 60.9% had the primary tumor tested. 5.2% had no mutations, 19% had 1 mutation, 28.6% had 2 mutations, 27% had 3 mutations and 20.2% had >4 mutations. The most common mutation guiding targeted therapy was KRAS (43.5%). 50% of patients had R0 resection and 19.3% went on to targeted therapy. 76.2% of resectable patients had a metastatic recurrence. 51.9% had targeted therapy for recurrence and/or stage 4 disease. The median time from diagnosis to MP was 9.9 months overall and 2.7 months for stage 4 patients. The median time from date of recurrence to MP was 7.7 months. Median length of follow up was 1.7 years. 14.9% had no evidence of disease at last follow up, 73% were alive with disease and 10.9% had died of the disease. Median overall survival was 55.8 months (CI 41.9 - 69.7). Conclusions: MP is utilized commonly in patients with stage 4 and recurrent CRC and occurs within 2.7 months and 7.7 months respectively. Further research is underway to evaluate if the information provided by MP improves outcomes in CRC, provides novel targets and will lead to increased clinical trial accrual.

Neoadjuvant chemoradiation for locally advanced rectal cancer with fluoropyrimidine alone or intensified with oxaliplatin: A systematic review and meta-analysis

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Background: Improved outcomes have been demonstrated with the use of neoadjuvant fluoropyrimidine-based chemoradiotherapy and total mesorectal excision for locally advanced rectal cancer. The addition of oxaliplatin in the adjuvant setting has also resulted in improved disease-free survival (DFS). A meta-analysis was performed to evaluate DFS and overall survival (OS) with the addition of oxaliplatin to standard neoadjuvant chemoradiation for locally advanced rectal cancer. Methods: A systematic literature review was performed. Randomized-controlled trials (RCTs) comparing the addition of oxaliplatin in the neoadjuvant setting (oxaliplatin group) to fluoropyrimidine-based chemoradiation (standard group) were included. The primary outcomes were DFS and OS; secondary outcomes were short-term surgical results, morbidity, and mortality. Results were combined using meta-analysis via linear mixed-effects models. Calculations were performed using R. Results: Of 73 studies identified, 4 reported DFS (n=3829) and 3 reported OS (n=2680). There was no difference in DFS between the standard and oxaliplatin groups amongst RCTs [HR 0.90 (0.64-1.26), p=0.5313]. There was no difference in OS [HR 0.93 (0.59-1.47), p=0.9894]. There was no significant heterogeneity between RCTs for primary outcomes. There was also no difference in pathologic complete response rate [OR 0.93 (0.77-1.14), p=0.4923), resection margin (R0) status [OR 1.01 (0.59-1.72), p=0.9846], circumferential resection margin status [OR 0.84 (0.50-1.41), p=0.5079], sphincter saving surgery rate [OR 0.87 (0.74-1.03), p=0.1103], grade 3-4 toxicity [OR 1.60 (0.88-2.92), p=0.1251], and 60-day mortality [OR 1.27 (0.50-3.25), p=0.6148]. There was significant heterogeneity between RCTs for R0 status, circumferential margin status, and grade 3-4 toxicity. Adjuvant treatment varied across studies. Conclusions: There are no short-term or long-term survival benefits with the addition of oxaliplatin to fluoropyrimidine-based chemoradiation in the neoadjuvant setting for locally advanced rectal cancer.

Peritoneal Carcinomatosis from Colon Cancer: A Systematic Review of the Data for Cytoreduction and Intraperitoneal Chemotherapy

A systematic review of the literature on the management of peritoneal carcinomatosis (PC) from colon cancer with cytoreductive surgery (CRS) and intraperitoneal chemotherapy (IPC) was undertaken using OVID Medline. Forty-six relevant studies were reviewed. Mean weighted overall morbidity following CRS and IPC was 49% (range 22-76%) and mortality was 3.6% (range 0-19%). Median overall survival ranged from 15 to 63 months, and 5-year overall survival ranged from 7 to 100%. This represents an improvement over historical treatment with systemic chemotherapy alone, even in the era of modern chemotherapeutic agents. Quality of life following surgery is initially decreased but improves with time and approaches baseline. Available data appear to support the treatment of PC from colon cancer with CRS and IPC. There is a large amount of variability among studies and few high-quality studies exist. Further studies are needed to standardize techniques.

Career plans and perceptions in readiness to practice of graduating general surgery residents in Canada

INTRODUCTION

Overall, 25% of American general surgery residents identified as not feeling confident operating independently at graduation, which may contribute to 70% pursuing further training. This study was undertaken to identify intended career plans of general surgery graduates in Canada on a national level, and perceived strengths and weaknesses of training that would affect transition to early practice.

METHODS

Questionnaires were distributed to graduating general surgery residents at a Canadian national review course in 2012 and 2013. Data were analyzed for overall trends.

RESULTS

Overall, 75% (78/104) of graduating residents responded in 2012 and 53% (50/95) in 2013. Greater than 60% of respondents were entering a fellowship program upon graduation (49/78 in 2012 and 37/50 in 2013); the most common fellowship choices were minimally invasive surgery (24% in 2012 and 39% in 2013) or surgical oncology (16% in 2012). Most residents reported that they were completing subspecialty training to meet career goals (64/85 overall) rather than feeling unprepared for practice (0/85 overall). Most residents planned on practicing in urban centers (54%) and academic hospitals (73%). Residents perceived a need for assistance for laparoscopic adrenalectomy, neck dissection, laparoscopic splenectomy, laparoscopic low anterior resection, groin dissection, and thyroidectomy.

CONCLUSIONS

An overwhelming majority of general surgery graduates plan to pursue fellowship training to meet career goals of working in urban, academic centers, rather than a perceived lack of competence. It is vital to describe operative competency expectations for residents and to promote a variety of practice opportunities following graduation.

Understanding surgical residents' postoperative practices and barriers and enablers to the implementation of an Enhanced Recovery After Surgery (ERAS) Guideline

INTRODUCTION

An Enhanced Recovery after Surgery (ERAS) Clinical Practice Guideline (CPG) was developed at the University of Toronto. Before implementation, general surgery residents were surveyed to assess their current stated practices and their perceived barriers and enablers to early discharge.

METHODS

The survey, which consisted of 33 questions related to the postoperative management of patients undergoing laparoscopic colectomy (LAC), open colectomy (OC) and open low anterior resection (LAR), was distributed to all residents. Chi-square and Fisher exact tests were used to test differences. Open-ended questions were analyzed using content analysis.

RESULTS

Of 77 residents surveyed, 58 (75%) responded. Residents stated that a fluid diet would be ordered on POD#0 and regular diet on POD#1 by 67.9% and 49.1%, respectively, following LAC, and 50.0% and 25.9%, respectively, following OC. On POD#1, 89.3% expected patients to ambulate following LAC compared with 67.9% following OC. Residents indicated that urinary catheters would be removed on POD#1 by 87% following LAC and by 81.3% following OC, and by POD#3 by 89.1% following LAR. However, in patients with an epidural, approximately 50% of residents stated that they would wait until it was removed. Overall, 76.4% of residents agreed that an ERAS CPG should be adopted. Residents cited setting expectations, encouragement of early ambulation and feeding, and good pain control as enablers to early discharge. However, patient and family expectations, surgeon preferences, and beliefs of the health care team were mentioned as barriers to early discharge.

CONCLUSION

Residents have a reasonable approach to the management of patients who underwent LAC, but there are gaps that exist in their management, especially following OC and LAR. Although most residents agreed with the implementation of an ERAS CPG, barriers exist, and strategies aimed at ensuring adherence with the recommendations are required.

Hepatic parenchymal preserving technique in the management of diffuse bilateral neuroendocrine tumour liver metastases: a feasible approach

BACKGROUND

Aggressive surgical resection of neuroendocrine tumour liver metastases (NET-LM) is associated with symptomatic relief. Debulking up to 90% of tumour burden, even with positive margins, may be beneficial. However, patients with diffuse hepatic metastases may not qualify for resection owing to associated insufficient remnant liver parenchyma. The purpose of this study is to describe an early experience with a hepatic parenchymal preserving (HPP) approach.

METHODS

We retrospectively reviewed our institutional neuroendocrine tumours database to identify patients with NET-LM, including symptomatic patients with extensive bilobar involvement, who underwent virtual volumetric assessment (VVA) combined with HPP resection between October 2008 and July 2011.

RESULTS

Our study involved 9 patients. The median number of liver metastases resected was 10 (range 4-50). Symptomatic improvement was observed in all patients. Immediate postoperative normalization of 5-HIAA 24-hour urine levels occurred in 89% of patients. Symptomatic and biochemical response remained stable or improved in 75% of patients at 12 months of follow-up. Four patients had postoperative complications. There was no 90-day mortality.

CONCLUSION

The described HPP approach is feasible and safe. Most patients experienced symptomatic and biochemical improvement. This reproducible approach could expand surgical resection options for patients with NET-LM and diffuse bilobar involvement.

Perioperative measures to optimize margin clearance in breast conserving surgery

Margin status is one of the most important determinants of local recurrence following breast conserving surgery. The fact that up to 60% of patients undergoing breast conserving surgery require re-excision highlights the importance of optimizing margin clearance. In this review we summarize the following perioperative measures that aim to enhance margin clearance: (1) patient risk stratification, specifically risk factors and nomograms, (2) preoperative imaging, (3) intraoperative techniques including wire-guided localization, radioguided surgery, intraoperative ultrasound-guided resection, intraoperative specimen radiography, standardized cavity shaving, and ink-directed focal re-excision; (4) and intraoperative pathology assessment techniques, namely frozen section analysis and imprint cytology. Novel surgical techniques as well as emerging technologies are also reviewed. Effective treatment requires accurate preoperative planning, developing and implementing a consistent definition of margin clearance, and using tools that provide detailed real-time intraoperative information on margin status.

Gene expression profiling in the neuroendocrine brain of male goldfish (Carassius auratus) exposed to 17alpha-ethinylestradiol

17-alpha ethinylestradiol (EE2), a pharmaceutical estrogen, is detectable in water systems worldwide. Although studies report on the effects of xenoestrogens in tissues such as liver and gonad, few studies to date have investigated the effects of EE2 in the vertebrate brain at a large scale. The purpose of this study was to develop a goldfish brain-enriched cDNA array and use this in conjunction with a mixed tissue carp microarray to study the genomic response to EE2 in the brain. Gonad-intact male goldfish were exposed to nominal concentrations of 0.1 nM (29.6 ng/l) and 1.0 nM (296 ng/l) EE2 for 15 days. Male goldfish treated with the higher dose of EE2 had significantly smaller gonads compared with controls. Males also had a significantly reduced level of circulating testosterone (T) and 17beta-estradiol (E2) in both treatment groups. Candidate genes identified by microarray analysis fall into functional categories that include neuropeptides, cell metabolism, and transcription/translation factors. Differentially expressed genes verified by real-time RT-PCR included brain aromatase, secretogranin-III, and interferon-related developmental regulator 1. Our results suggest that the expression of genes in the sexually mature adult brain appears to be resistant to low EE2 exposure but is affected significantly at higher doses of EE2. This study demonstrates that microarray technology is a useful tool to study the effects of endocrine disrupting chemicals on neuroendocrine function and suggest that exposure to EE2 may have significant effects on localized E2 synthesis in the brain by affecting transcription of brain aromatase.

Analysis of near-infrared spectroscopy and indocyanine green dye dilution with Monte Carlo simulation of light propagation in the adult brain

Near-infrared spectroscopy (NIRS) combined with indocyanine green (ICG) dilution is applied externally on the head to determine the cerebral hemodynamics of neurointensive care patients. We applied Monte Carlo simulation for the analysis of a number of problems associated with this method. First, the contamination of the optical density (OD) signal due to the extracerebral tissue was assessed. Second, the measured OD signal depends essentially on the relative blood content (with respect to its absorption) in the various transilluminated tissues. To take this into account, we weighted the calculated densities of the photon distribution under baseline conditions within the different tissues with the changes and aberration of the relative blood volumes that are typically observed under healthy and pathologic conditions. Third, in case of NIRS ICG dye dilution, an ICG bolus replaces part of the blood such that a transient change of absorption in the brain tissues occurs that can be recorded in the OD signal. Our results indicate that for an exchange fraction of Delta=30% of the relative blood volume within the intracerebral tissue, the OD signal is determined from 64 to 74% by the gray matter and between 8 to 16% by the white matter maximally for a distance of d=4.5 cm.

A new subdural probe for combined intracranial pressure (ICP) and cerebral blood flow (CBF) monitoring

We report the development of a new subdural probe for combined intracranial pressure (ICP) and cerebral blood flow (CBF) monitoring with near infrared spectroscopy (NIRS) and indocyanine green (ICG) dye dilution. For NIRS a conventional subdural ICP monitoring probe was supplied with two fiber bundles and 90-degree prisms. Injections of 25 mg ICG were performed. Regional values for the mean transit time of ICG (rmtt(ICG)), cerebral blood flow (rCBF) and cerebral blood volume (rCBV) were calculated. With prototypes of the probe in two patients with intracerebral haemorrhage 18 comparative measurements obtained simultaneously with conventional NIRS (optodes placed on the skin) and the subdural NIRS probe were performed. The new subdural NIRS probe allows combined monitoring of ICP and cerebral hemodynamics in the brain directly, without the influence of extracerebral tissue.

New methods for monitoring cerebral oxygenation and hemodynamics in patients with subarachnoid hemorrhage

Radiographic cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) do not reflect cerebral hemodynamics and oxygenation and may occur in the absence of clinical deficit and vice-versa. This report is to describe preliminary findings in further development of a non invasive method to estimate regional cerebral oxygenation and perfusion. Measurements were performed with a technique combining near infrared spectroscopy (NIRS) and indocyaningreen (ICG) dye dilution. Successful data analysis has been performed based on the decomposition in pulsatile and non-pulsatile components of NIRS absorption data collected before and during the passage of ICG through the vascular bed under the NIRS-detector. First measurements in patients with CVS suggest that the technique could become a powerful tool in the detection and treatment of CVS. This non invasive technique can be done at the bedside, it seems to be safe, easy to perform and less time-consuming compared to conventional techniques. The influence of extracerebral bone and surface tissue on cerebral NIRS signal has not been clarified yet. Therefore a new subdural NIRS probe has been developed, which gives the opportunity to measure directly the concentration of the chromophores in the brain without the influence of extracerebral contamination. In future comparative measurements with conventional NIRS probes on the scalp will allow to quantify and eliminate extracerebral contamination from the NIRS signal.

The use of systemic antibiotics in seven community hospitals in Northern Israel

This study evaluated and compared the usage and costs of antibiotics in seven hospitals in the North of Israel and was the first of its kind. We also attempted to determine whether the presence of an Infectious Diseases Unit or Consultant affects antibiotic usage and costs.

Growth and development of potatoes under salinity and water deficit

The agronomic and physiological responses of potato to salinity and to water deficits were determined. The experiment consisted of five treatments: three salinity levels and two restricted amounts of water. Plant height, leaf area and fresh weight accumulation were significantly affected by the salinity and moisture treatments. Stem number, leaf elongation and the content of dry-matter in leaves, stems and tubers were hardly affected. Harvest index, an important agronomic trait, was markedly improved by the different treatments.

Acceptance of mental retardation and help-seeking by mothers and fathers of children with mental retardation

Help-seeking preferences of parents of children with mental retardation were examined. A specially constructed Acceptance of Retardation Scale was administered to 25 fathers and 25 mothers. Respondents were asked to consider a number of need situations associated with their child's retardation and rate the likelihood that they would try to help themselves or seek external help from various sources. Results showed that mothers and fathers may have different help-seeking patterns. The fathers' help-seeking behavior seems to be instrumental, whereas mothers seem to be affected by ego considerations. Several demographic correlates of help-seeking behavior were also collected. Implications were discussed.

Forty years later: long-term consequences of massive traumatization as manifested by Holocaust survivors from the city and the Kibbutz

The present study explored the differences between male and female Holocaust survivors (n = 34) and controls (n = 34) who were similar to the survivors but had not been victims of the Holocaust. Half of the respondents were from the city and the other half were from the Kibbutz. The main dependent measures included the CAQ, the TSCS, and a specially designed Centrality of Family scale. Survivors were worse off psychologically than comparison individuals on the quality of emotional life, on emotional expression, and on the quality of interpersonal relations. Also, survivors assigned relatively greater value to their postwar families. City survivors seem to be worse off than Kibbutz survivors, and male survivors from the city had the lowest scores on several key subscales. These data were corroborated and extended by a content analysis of an open-ended interview conducted after the objective measures had been completed. The findings and their implications for understanding the effects of massive traumatization over individuals' life cycles are discussed.

Forty years later: Long-term consequences of massive traumatization as manifested by Holocaust survivors from the city and the Kibbutz

The present study explored the differences between male and female Holocaust survivors (n = 34) and controls (n = 34) who were similar to the survivors but had not been victims of the Holocaust. Half of the respondents were from the city and the other half were from the Kibbutz. The main dependent measures included the CAQ, the TSCS, and a specially designed Centrality of Family scale. Survivors were worse off psychologically than comparison individuals on the quality of emotional life, on emotional expression, and on the quality of interpersonal relations. Also, survivors assigned relatively greater value to their postwar families. City survivors seem to be worse off than Kibbutz survivors, and male survivors from the city had the lowest scores on several key subscales. These data were corroborated and extended by a content analysis of an open-ended interview conducted after the objective measures had been completed. The findings and their implications for understanding the effects of massive traumatization over individuals' life cycles are discussed.

Satisfaction with social support during crisis: intimacy and self-esteem as critical determinants

Satisfaction with social support was studied longitudinally in a group of 113 Israeli women following the outcome of both normal and medically complicated pregnancies. Greater intimacy with spouse and with friends were found to be related to greater satisfaction with support received during this crisis period. Intimate ties contributed to satisfaction with support independent of self-esteem, social network parameters, and type of pregnancy outcome. Social network parameters and pregnancy outcome were not found to be related to satisfaction with support. Among women low in self-esteem, greater intimacy with family was found to be related to lower satisfaction with support if the women lacked intimate ties with spouse or a friend. The findings were discussed in light of clinical and social psychological theories regarding reaction to aid.

Satisfaction with social support during crisis: Intimacy and self-esteem as critical determinants

Satisfaction with social support was studied longitudinally in a group of 113 Israeli women following the outcome of both normal and medically complicated pregnancies. Greater intimacy with spouse and with friends were found to be related to greater satisfaction with support received during this crisis period. Intimate ties contributed to satisfaction with support independent of self-esteem, social network parameters, and type of pregnancy outcome. Social network parameters and pregnancy outcome were not found to be related to satisfaction with support. Among women low in self-esteem, greater intimacy with family was found to be related to lower satisfaction with support if the women lacked intimate ties with spouse or a friend. The findings were discussed in light of clinical and social psychological theories regarding reaction to aid.