A framework for role allocation in education, research and leadership services in Canadian academic divisions of general surgery: a modified Delphi consensus.

BACKGROUND: Moving toward a funding standard similar to that for clinical services for roles essential to the functioning of education, research and leadership services within divisions of general surgery is necessary to strengthen divisional resilience. We aimed to identify roles and underlying tasks in these services central to sustainable functioning of Canadian academic divisions of general surgery. METHODS: Between June 2018 and October 2020, we used a 4-step modified Delphi method (online survey, face-to-face nominal group technique [n = 12], semistructured telephone interview [n = 8] and nominal group technique [n = 12]) to achieve national consensus from an expert panel of all 17 heads of academic divisions of general surgery in Canada on the roles and accompanying tasks essential to education, research and leadership services within an academic division of general surgery. We used 70% agreement to determine consensus. RESULTS: The expert panel agreed that a framework for role allocation in education, research and leadership services was relevant and necessary. Consensus was reached for 7 roles within the educational service, 3 roles within the research service and 5 roles within the leadership service. CONCLUSION: Our framework represents a national consensus that defines role standards for education, research and leadership services in Canadian academic divisions of general surgery. The framework can help divisions build resiliency, and enable sustained and deliberate advances in these services.

PATCH-DP: a single-arm phase II trial of intra-operative application of HEMOPATCH™ to the pancreatic stump to prevent post-operative pancreatic fistula following distal pancreatectomy.

BACKGROUND: Post-operative pancreatic fistula (POPF) is the most significant cause of morbidity following distal pancreatectomy. Hemopatch™ is a thin, bovine collagen-based hemostatic sealant. We hypothesized that application of Hemopatch™ to the pancreatic stump following distal pancreatectomy would decrease the incidence of clinically-significant POPF. METHODS: We conducted a prospective, single-arm, multicentre phase II study of application of Hemopatch™ to the pancreatic stump following distal pancreatectomy. The primary outcome was clinically-significant POPF within 90 days of surgery. A sample size of 52 patients was required to demonstrate a 50% relative reduction in Grade B/C POPF from a baseline incidence of 20%, with a type I error of 0.2 and power of 0.75. Secondary outcomes included incidence of POPF (all grades), 90-day mortality, 90-day morbidity, re-interventions, and length of stay. RESULTS: Adequate fixation Hemopatch™ to the pancreatic stump was successful in all cases. The rate of grade B/C POPF was 25% (95%CI: 14.0-39.0%). There was no significant difference in the incidence of grade B/C POPF compared to the historical baseline (p = 0.46). The 90-day incidence of Clavien-Dindo grade ≥3 complications was 26.9% (95%CI: 15.6-41.0%). CONCLUSION: The use of Hemopatch™ was not associated with a decreased incidence of clinically-significant POPF compared to historical rates. (NCT03410914).

Pre-operative stenting and complications following pancreatoduodenectomy for pancreatic cancer: an analysis of the ACS-NSQIP registry.

BACKGROUND: Historically, pre-operative biliary stenting has been associated with higher infectious complication rates following pancreatoduodenectomy. However, alleviation of biliary obstruction is necessary for consideration of pre-operative chemotherapy, which may improve disease-free survival, or for mitigation of symptoms while awaiting surgery. Our aim is to compare contemporary post-operative complication risk among patients with pre-operative endoscopic retrograde cholangiopancreatography (ERCP) stenting compared to those without. METHODS: Patients who underwent a pancreatoduodenectomy for pancreatic cancer with biliary obstruction within the ACS-NSQIP registry from 2014 to 2017 were identified. The primary outcome was to compare the risk of 30-day complication (composite outcome) between patients with and without pre-operative ERCP stenting. Propensity score matching was used to ensure balanced baseline characteristics and log-binomial regression models were used to estimate risk ratios for overall perioperative complication between groups. RESULTS: From 6073 patients with obstructive jaundice undergoing pancreatoduodenectomy for pancreatic cancer, 92% (5564) were eligible for the study. After performing a propensity score matching on 20 baseline characteristics, 952 patients without stenting were matched to up to four patients who received pre-operative ERCP stenting (n = 3467) for a matched cohort of 4419. A total of 1901 (55%) patients with pre-operative ERCP stenting experienced a post-operative complication compared to 501 (53%) patients without stenting (risk ratio 1.04, 95% CI 0.97-1.11, p = 0.23). CONCLUSION: Pre-operative ERCP stenting was not associated with an increased risk of post-operative complication in patients undergoing pancreatoduodenectomy with obstructive jaundice. Biliary stenting may be safely considered for symptom relief and to potentially facilitate pre-operative chemotherapy for pancreatic cancer.

Venous thromboembolism in emergency general surgery patients: a single-centre retrospective cohort study

Background: There is limited literature on the risk of venous thromboembolism (VTE) in emergency general surgery (EGS) patients. We undertook this study to identify the rate of symptomatic VTE for patients undergoing EGS operations. Methods: We conducted a retrospective cohort study evaluating EGS patients who underwent operative intervention between March and December 2014. Data collected included patient demographics, type of procedure, risk of VTE, VTE prophylaxis, development of symptomatic VTE, and mortality. Results: We included 767 patients in our analysis. The mean age was 53 ± 19.7 years, and 52.2% of patients were female. Eighteen patients (2.3%) experienced VTE in hospital and 12 (1.6%) experienced VTE after discharge. Only 66% of patients received appropriate VTE prophylaxis. High-risk patients had a higher VTE rate (7.4% v. 2.3%, p < 0.001) and higher mortality (17.6% v. 4.0%, p < 0.001) than lowto moderate-risk patients. Conclusion: The risk of VTE in patients requiring EGS is significant and persists after hospital discharge. Further studies on quality improvement with VTE prophylaxis are warranted.

Contexte: La littérature sur le risque de thromboembolie veineuse (TEV) chez les patients soumis à une chirurgie générale urgente est limitée. Nous avons entrepris cette étude afin de mesurer le taux de TEV symptomatique chez les patients ayant subi une intervention urgente en chirurgie générale. Méthodes: Nous avons procédé à une étude de cohorte rétrospective sur les patients qui ont subi une chirurgie générale urgente entre mars et décembre 2014. Parmi les données recueillies, mentionnons données démographiques, type d'intervention, risque de TEV, thromboprophylaxie, apparition d'une TEV symptomatique et mortalité. Résultats: Nous avons inclus 767 patients dans notre analyse. L'âge moyen était de 53 ± 19,7 ans et 52,2 % des patients étaient de sexe féminin. Dix-huit patients (2,3 %) ont présenté une TEV en cours d'hospitalisation et 12 (1,6 %) après leur congé. Seulement 66 % des patients ont reçu une thromboprophylaxie adéquate. Les patients à haut risque ont présenté des taux de TEV (7,4 % c. 2,3 %, p < 0,001) et de mortalité (17,6 % c. 4,0 %, p < 0,001) plus élevés que les patients présentant un risque faible à modéré. Conclusion: Le risque de TEV chez les patients soumis à une chirurgie générale urgente est significatif et persiste après le congé hospitalier. Il faudra mener des études plus approfondies sur l'amélioration de la qualité de la thromboprophylaxie.

Health and Economic Impact of Intensive Surveillance for Distant Recurrence After Curative Treatment of Colon Cancer: A Mathematical Modeling Study.

BACKGROUND: Intensive surveillance strategies are currently recommended for patients after curative treatment of colon cancer, with the aim of secondary prevention of recurrence. Yet, intensive surveillance has not yielded improvements in overall patient survival compared with minimal follow-up, and more intensive surveillance may be costlier. OBJECTIVE: The purpose of this study was to estimate the quality-adjusted life-years, economic costs, and cost-effectiveness of various surveillance strategies after curative treatment of colon cancer. DESIGN: A Markov model was calibrated to reflect the natural history of colon cancer recurrence and used to estimate surveillance costs and outcomes. SETTINGS: This was a decision-analytic model. PATIENTS: Individuals entered the model at age 60 years after curative treatment for stage I, II, or III colon cancer. Other initial age groups were assessed in secondary analyses. MAIN OUTCOME MEASURES: We estimated the gains in quality-adjusted life-years achieved by early detection and treatment of recurrence, as well as the economic costs of surveillance under various strategies. RESULTS: Cost-effective strategies for patients with stage I colon cancer improved quality-adjusted life-expectancy by 0.02 to 0.06 quality-adjusted life-years at an incremental cost of $1702 to $13,019. For stage II, they improved quality-adjusted life expectancy by 0.03 to 0.09 quality-adjusted life-years at a cost of $2300 to $14,363. For stage III, they improved quality-adjusted life expectancy by 0.03 to 0.17 quality-adjusted life-years for a cost of $1416 to $17,631. At a commonly cited willingness-to-pay threshold of $100,000 per quality-adjusted life-year, the most cost-effective strategy for patients with a history of stage I or II colon cancer was liver ultrasound and chest x-ray annually. For those with a history of stage III colon cancer, the optimal strategy was liver ultrasound and chest x-ray every 6 months with CEA measurement every 6 months. LIMITATIONS: The study was limited by model structure assumptions and uncertainty around the values of the model's parameters. CONCLUSIONS: Given currently available data and within the limitations of a model-based decision-analytic approach, the effectiveness of routine intensive surveillance for patients after treatment of colon cancer appears, on average, to be small. Compared with testing using lower cost imaging, currently recommended strategies are associated with cost-effectiveness ratios that indicate low value according to well-accepted willingness-to-pay thresholds in the United States. See Video Abstract at http://links.lww.com/DCR/A921.

The impact of a new hepatopancreatobiliary surgery program on the management of pancreatic cancer at Health Sciences North

Background: Centralization of specialist services to urban centres presents a challenge to patients living in rural communities. The hepatopancreatobiliary surgery (HPB) program at Health Sciences North (HSN) is the tenth and newest HPB centre by Cancer Care Ontario and presents a unique opportunity to evaluate the barriers to delivering HPB cancer care to patients in northern Ontario. Methods: We retrospectively reviewed the cases of patients referred to the Northeastern Ontario Cancer Centre and HSN with a pancreatic cancer diagnosis between 2009 and 2015. July 2013 marked the inception of the HPB surgical program. Our primary outcome was time to HPB surgical consultation. Secondary outcomes included distance of travel and time to curative intent operation. Results: Our population consisted of 207 patients (98 pre-HPB v. 109 post-HPB). Median time to consultation with an HPB surgeon was decreased in the post-HPB group (43 v. 11 d, p < 0.001). An increased proportion of patients with pancreatic malignancies in the post-HPB group received HPB surgical consultations (34% v. 74%, p < 0.001), with decreased median distance travelled to surgical consultation (411 v. 79 km, p < 0.001). Time to curative intent operation or medical oncology consultation did not significantly increase. Conclusion: A new HPB program appears to have facilitated the proportion of patients with pancreatic malignancies at HSN receiving an HPB surgical consultation. Patients received complex surgeries, closer to their home regions. It is anticipated that these changes may affect overall outcomes and patient satisfaction and will be the focus of future investigations.

Contexte: La concentration des services spécialisés dans les centres urbains pose un défi pour les patients des communautés rurales. Le programme de chirurgie hépatopancréatobiliaire (HPB) d'Horizon Santé-Nord (HSN) est le 10e et plus récent centre HPB d'Action Cancer Ontario; il offre une occasion unique d'évaluer les obstacles à la prestation des soins oncologiques HPB aux patients du Nord de l'Ontario. Méthodes: Nous avons passé en revue de manière rétrospective les cas adressés au Centre de cancérologie du Nord-Est de l'Ontario et à HSN pour un diagnostic de cancer du pancréas entre 2009 et 2015. Le programme chirurgical HPB a été lancé en juillet 2013. Notre principal paramètre était le délai d'obtention d'une consultation pour une chirurgie HPB. Les paramètres secondaires incluaient la distance à parcourir et le délai d'obtention d'une intervention à visée curative. Résultats: Notre population comportait 207 patients (98 pré-HPB c. 109 post-HPB). Le délai médian d'obtention de la consultation en chirurgie HPB a diminué dans le groupe post-HPB (43 j c. 11 j, p < 0,001). Une proportion plus grande de patients atteints de cancer du pancréas dans le groupe post-HPB a obtenu une consultation pour chirurgie HPB (34 % c. 74 %, p < 0,001), et une diminution de la distance médiane à parcourir pour se rendre à la consultation a été constatée (411 km c. 79 km, p < 0,001). Le délai d'obtention de la chirurgie à visée curative ou de la consultation en oncologie médicale n'a pas augmenté significativement. Conclusion: Le nouveau programme HPB semble avoir permis d'accroître la proportion de patients atteints de cancer du pancréas ayant pu bénéficier d'une consultation pour chirurgie HPB. Les patients ont pu subir des chirurgies complexes plus près de chez eux. On prévoit que ces modifications auront une incidence sur les paramètres globaux et la satisfaction des patients et qu'elles feront l'objet d'études.

Intra-Abdominal Hypertension Is More Common Than Previously Thought: A Prospective Study in a Mixed Medical-Surgical ICU.

OBJECTIVES: To determine the prevalence of intra-abdominal hypertension in mixed medical-surgical critically ill patients using modern definitions and measurement techniques. Secondarily to determine variables associated with intra-abdominal hypertension and ICU mortality. DESIGN: A prospective observational study. SETTING: Single institution trauma, medical and surgical ICU in Canada. PATIENTS: Consecutive adult patients admitted to the ICU (n = 285). INTERVENTION: Intra-abdominal pressure measurements twice a day during admission to the ICU. MEASUREMENTS AND MAIN RESULTS: In 285 patients who met inclusion criteria, 30% were diagnosed with intra-abdominal hypertension at admission and a further 15% developed intra-abdominal hypertension during admission. The prevalence of abdominal compartment syndrome was 3%. Obesity, sepsis, mechanical ventilation, and 24-hour fluid balance (> 3 L) were all independent predictors for intra-abdominal hypertension. Intra-abdominal hypertension occurred in 28% of nonventilated patients. Admission type (medical vs surgical vs trauma) was not a significant predictor of intra-abdominal hypertension. Overall ICU mortality was 20% and was significantly higher for patients with intra-abdominal hypertension (30%) compared with patients without intra-abdominal hypertension (11%). Intra-abdominal hypertension of any grade was an independent predictor of mortality (odds ratio, 3.33; 95% CI, 1.46-7.57). CONCLUSIONS: Intra-abdominal hypertension is common in both surgical and nonsurgical patients in the intensive care setting and was found to be independently associated with mortality. Despite prior reports to the contrary, intra-abdominal hypertension develops in nonventilated patients and in patients who do not have intra-abdominal hypertension at admission. Intra-abdominal pressure monitoring is inexpensive, provides valuable clinical information, and there may be a role for its routine measurement in the ICU. Future work should evaluate the impact of early interventions for patients with intra-abdominal hypertension.

Carbon monoxide and hydrogen sulphide reduce reperfusion injury in abdominal compartment syndrome.

BACKGROUND: Carbon monoxide (CO)- and hydrogen sulphide-releasing molecules (CORM-3 and GYY4137, respectively) have been shown to be potent antioxidant and antiinflammatory agents at the tissue and systemic level. We hypothesized that both CORM-3 and GYY4137 would reduce the significant organ dysfunction associated with abdominal compartment syndrome (ACS). MATERIAL AND METHODS: Randomized trial was conducted where ACS was maintained for 2 hours in 27 rats using an abdominal plaster cast and intraperitoneal CO2 insufflation at 20 mmHg. Three experimental groups underwent ACS and received an experimental molecule at the time of decompression: inactive CORM-3, active CORM-3, and GYY4137, whereas three groups underwent no ACS to serve as a sham. Sinusoidal perfusion, inflammatory response and cell death were quantified in exteriorized livers. Respiratory, liver, and renal dysfunction was assessed biochemically. RESULTS: Hepatocellular death and the number of activated leukocytes within postsinusoidal venules were significantly increased in rats with ACS (16-fold increase, 17-fold leukocyte activation, respectively, P < 0.05). Administration of CORM-3 or GYY4137 resulted in a significant decrease of both parameters (P = 0.03 and P = 0.009). ACS resulted in an increase in markers of renal and liver injury; CORM-3 or GYY4137 partially restored levels to those seen in sham animals. Myeloperoxidase was significantly elevated in the ACS group in lung, liver, and small intestine (P = 0.0002, P = 0.01, and P = 0.08, respectively). CORM-3 treatment, but not GYY4137, was able to completely block the response (65 ± 11 U/ml and 92 ± 18 U/ml, respectively versus 110 ± 10U/ml in the ACS group, lung tissue). CONCLUSIONS: We have demonstrated the effect of two molecules, CO and hydrogen sulphide, on tempering the reperfusion-associated metabolic and organ derangements in ACS. CORM-3 demonstrated a greater effect than GYY4137 and was able to restore most of the measured parameters to levels comparable to sham.

Beyond just the operating room: characterizing the complete caseload of a tertiary acute care surgery service.

BACKGROUND: Most studies evaluating acute care surgery (ACS) models of care for patients with emergency general surgery (EGS) conditions have focused on patients who undergo surgery while admitted under the care of the ACS service. The purpose of this study was to prospectively examine the case mix of admissions and consultations to an ACS service at a tertiary centre to identify the frequency and distribution of both operatively and nonoperatively managed EGS conditions. METHODS: In this prospective cohort study, we evaluated consecutive patients assessed by the ACS team between July 1 and Aug. 31, 2015, at a large Canadian tertiary care centre. This included all consultations and outside hospital transfers. Diagnoses, demographic characteristics, comorbidities, intervention(s), complications, readmission and in-hospital death were captured. RESULTS: The ACS team was involved in the care of 359 patients, 176 (49.0%) of whom were admitted under the direct care of the ACS team. Nonoperative care was indicated in 82 patients (46.6%) admitted to the ACS service and 151 (82.5%) of those admitted to a non-ACS service (p < 0.001). Bowel obstruction (37 patients [21.0%]) was the most common reason for admission, followed by wound/abscess (24 [13.6%), biliary disease (24 [13.6%]) and appendiceal disease (23 [13.1%]). Rates of 30-day return to the emergency department and readmission were 17.0% and 9.1%, respectively, and the in-hospital mortality rate was 1.7%. CONCLUSION: Acute care surgery teams care for a wide breadth of disease, a considerable amount of which is managed nonoperatively.

CONTEXTE: La plupart des études qui ont évalué les modèles de soins chirurgicaux aigus (SCA) chez des patients souffrant de problèmes de santé nécessitant un traitement de chirurgie générale (TCG) d'urgence ont porté sur des patients ayant subi une intervention lors de leur admission dans un service de SCA. Le but de cette étude était d'analyser de manière prospective la clientèle admise ou vue en consultation dans le service de SCA d'un centre de soins tertiaires pour connaître la fréquence et la distribution des problèmes de santé nécessitant un TCG d'urgence effectivement traités chirurgicalement ou autrement. MÉTHODES: Dans cette étude de cohorte prospective, nous avons évalué des patients consécutifs vus par l'équipe de SCA entre le 1er juillet et le 31 août 2015 dans un grand centre canadien de soins tertiaires. Cela incluait toutes les consultations et les transferts en provenance d'autres hôpitaux. Nous avons noté les diagnostics, les caractéristiques démographiques, les comorbidités, les interventions, les complications, réadmissions et les décès en cours d'hospitalisation. RÉSULTATS: L'équipe de SCA a assuré les soins de 359 patients, dont 176 (49,0 %) avaient été admis directement au service de SCA. Des soins non chirurgicaux étaient indiqués chez 82 patients (46,6 %) admis au service de SCA et chez 151 (82,5 %) patients admis dans d'autres services (p < 0,001). L'obstruction intestinale (37 patients [21,0 %]) a été la raison la plus fréquente des admissions, suivie de blessure ou d'abcès (24 patients [13,6 %), maladie biliaire (24 patients [13,6 %]) et maladie appendiculaire (23 patients [13,1 %]). Les taux de retour aux urgences et de réadmission dans les 30 jours ont été de 17,0 % et de 9,1 %, respectivement, et le taux de mortalité en cours d'hospitalisation a été de 1,7 %. CONCLUSION: Les équipes de soins chirurgicaux aigus prennent en charge un vaste éventail de pathologies, dont une part importante est gérée de manière non chirurgicale.

Implementation of an acute care emergency surgical service: a cost analysis from the surgeon's perspective.

BACKGROUND: Acute care surgical services provide comprehensive emergency general surgical care while potentially using health care resources more efficiently. We assessed the volume and distribution of emergency general surgery (EGS) procedures before and after the implementation of the Acute Care and Emergency Surgery Service (ACCESS) at a Canadian tertiary care hospital and its effect on surgeon billings. METHODS: This single-centre retrospective case-control study compared adult patients who underwent EGS procedures between July and December 2009 (pre-ACCESS), to those who had surgery between July and December 2010 (post-ACCESS). Case distribution was compared between day (7 am to 3 pm), evening (3 pm to 11 pm) and night (11 pm to 7 am). Frequencies were compared using the χ(2) test. RESULTS: Pre-ACCESS, 366 EGS procedures were performed: 24% during the day, 55% in the evening and 21% at night. Post-ACCESS, 463 operations were performed: 55% during the day, 36% in the evening and 9% at night. Reductions in night-time and evening EGS were 57% and 36% respectively (p < 0.001). Total surgeon billings for operations pre- and post-ACCESS were $281 066 and $287 075, respectively: remuneration was $6008 higher post-ACCESS for an additional 97 cases (p = 0.003). Using cost-modelling analysis, post-ACCESS surgeon billing for appendectomies, segmental colectomies, laparotomies and cholecystectomies all declined by $67 190, $125 215, $66 362, and $84 913, respectively (p < 0.001). CONCLUSION: Acute care surgical services have dramatically shifted EGS from nighttime to daytime. Cost-modelling analysis demonstrates that these services have cost-savings potential for the health care system without reducing overall surgeon billing.

CONTEXTE: La mise sur pied d'un service d'urgences chirurgicales permet d'offrir des soins de chirurgie générale d'urgence complets, tout en assurant une utilisation potentiellement plus efficiente des ressources en soins de santé. Nous avons évalué le volume et la distribution des interventions de chirurgie générale d'urgence (CGU) avant et après la mise sur pied d'un service de soins chirurgicaux d'urgence (SSCU) dans un hôpital de soins tertiaires canadien et mesuré son effet sur la facturation émise par les chirurgiens. MÉTHODES: Cette étude rétrospective cas­témoins réalisée dans un seul centre a comparé des patients adultes soumis à des interventions de CGU entre juillet et décembre 2009 (pré-SSCU) à ceux qui avaient subi une intervention chirurgicale entre juillet et décembre 2010 (post-SSCU). Nous avons comparé la distribution des cas entre les quarts de jour (de 7 heures à 15 heures), de soir (de 15 heures à 23 heures) et de nuit (de 23 heures à 7 heures). Nous avons utilisé le test χ2 pour comparer les fréquences. RÉSULTATS: Pendant la période pré-SSCU, 366 interventions de CGU ont été effectuées : 24 % durant le jour, 55 % durant la soirée et 21 % durant la nuit. Après la mise en place du SSCU, 463 opérations ont été effectuées : 55 % durant le jour, 36 % durant la soirée et 9 % durant la nuit. Les réductions observées au plan des CGU réalisées durant la nuit et la soirée ont été de 57 % et 36 %, respectivement (p < 0,001). La facturation totale soumise par les chirurgiens pour les interventions réalisées avant et après la mise en place du SSCU a été respectivement de 281 066 $ et de 287 075 $ : la rémunération a été de 6008 $ supérieure après la mise en place du SSCU, pour 97 cas additionnels (p = 0,003). L'analyse de modélisation des coûts a révélé qu'après la mise en place du SSCU, la facturation soumise par les chirurgiens pour les appendicectomies, les colectomies segmentaires, les laparotomies et les cholécystectomies a diminué de 67 190 $, 125 215 $, 66 362 $ et 84 913 $, respectivement (p < 0,001). CONCLUSION: Les services de soins chirurgicaux d'urgence ont considérablement modifié les interventions de CGU, les faisant passer des quarts de travail de nuit à ceux du jour. L'analyse de modélisation des coûts démontre que le SSCU recèle un potentiel d'économies pour le système de soins de santé sans réduire la facturation totale émise par les chirurgiens.

An investigation of the effects of ketoprofen following rumen fistulation surgery in lactating dairy cows.

Post-operative pain management following rumen surgery is not common practice. We examined the effect of providing the pain medication ketoprofen to dairy cattle following the first stage of a rumen cannulation surgery, which involves an incision in the body wall and exteriorizing and clamping the rumen. The results of this study provide clear evidence that the first stage of the surgery was painful and ketoprofen at the time of and 24 h following surgery, alleviated some, but not all, of the post-surgical pain. Pain mitigation should be included when performing flank surgery in cattle.

Une enquête sur les effets du kétoprofène administré à des vaches laitières après une chirurgie de fistulisation du rumen. Ce n'est pas pratique courante d'administrer des analgésiques suite à la chirurgie du rumen. Cette étude a examiné les effets du médicament kétoprofène chez les vaches laitières après la première étape d'une chirurgie de fistulisation du rumen. Cette chirurgie consiste à faire une incision sur le côté gauche de l'abdomen pour ensuite sortir une partie du rumen de l'abdomen et de le fixer avec une attache. Les résultats de cette étude démontrent que la première étape était douloureuse et que l'administration du kétoprofène, à la fin de la chirurgie, ainsi qu'après 24 h, a atténué une partie de la douleur chirurgicale sans toutefois l'enlever complètement. L'administration d'analgésiques devrait faire partie intégrante du traitement lors des chirurgies abdominales chez les bovins.(Traduit par les auteurs).

Survival benefit of neoadjuvant FOLFIRINOX for patients with borderline resectable pancreatic cancer.

Backgrounds/Aims: While patients with borderline resectable pancreatic cancer (BRPC) are a target population for neoadjuvant chemotherapy (NAC), formal guidelines for neoadjuvant therapy are lacking. We assessed the perioperative and oncological outcomes in patients with BRPC undergoing NAC with FOLFIRINOX for patients undergoing upfront surgery (US). Methods: The AHPBA criteria for borderline resectability and/or a CA19-9 level > 100 µ/mL defined borderline resectable tumors retrieved from a prospectively populated institutional registry from 2007 to 2020. The primary outcome was overall survival (OS) at 1 and 3 years. A Cox Proportional Hazard model based on intention to treat was used. A receiver-operator characteristics (ROC) curve was constructed to assess the discriminatory capability of the use of CA19-9 > 100 µ/mL to predict resectability and mortality. Results: Forty BRPC patients underwent NAC, while 46 underwent US. The median OS with NAC was 19.8 months (interquartile range [IQR], 10.3-44.24) vs. 10.6 months (IQR, 6.37-17.6) with US. At 1 year, 70% of the NAC group and 41.3% of the US group survived (p = 0.008). At 3 years, 42.5 % of the NAC group and 10.9% of the US group survived (p = 0.001). NAC significantly reduced the hazard of death (adjusted hazard ratio, 0.20; 95% confidence interval, 0.07-0.54; p = 0.001). CA19-9 > 100 µ/mL showed poor discrimination in predicting mortality, but was a moderate predictor of resectability. Conclusions: We found a survival benefit of NAC with FOLFIRINOX for BRPC. Greater pre-treatment of CA19-9 and multivessel involvement on initial imaging were associated with progression of the disease following NAC.

Short communication: use of a mechanical brush by Holstein dairy cattle around parturition.

Grooming is a normal behavior that may contribute to relief of stress. The purpose of this study was to investigate the effect of access to a mechanical brush on auto-grooming behavior in parturient cows. The hypothesis was that cows would increase the total time spent scratching using the brush if they had access to a brush around the time of calving, whereas auto-grooming would be lower for the brush group compared with the no-brush group. The use of a mechanical brush was analyzed both in a group-housed pen (72 to 48 h before calving) and in an individual maternity pen (6h before to 6h after calving) in 16 multiparous Holstein cows. In the maternity pen, cows were randomly assigned to have access to the brush or not. The provision of a mechanical brush in the individual maternity pen did not change the amount of time spent auto-grooming but cows did use the brush before calving and after the calf was removed. Despite being housed in pens containing a brush, cows failed to use it when the calf was present. However, cows with access to a brush spent more time licking their calves in the first hour postcalving (ß=8.7 min; 95% confidence interval: 1.5, 15.8) than cows that did not have access to a brush. Regardless of treatment, cows increased the time spent auto-grooming and scratching following separation of their newborn calf (ß=1.4 min; 95% confidence interval: 0.46, 2.3 and ß=0.07 min; 95% confidence interval: 0.02, 0.12, respectively). Further research is warranted to investigate possible benefits of mechanical brush devices at the time of calving, particularly for cows that experience difficult calving and require manual or mechanical assistance.

The effect of administering ketoprofen on the physiology and behavior of dairy cows following surgery to correct a left displaced abomasum.

Surgical correction of left displaced abomasum (LDA) is common in lactating dairy cattle. Despite the growing acceptance that abdominal surgery is painful, few cows are administered analgesia following LDA surgery. The objective of this research was to examine the effect of administering a label dose of ketoprofen on physiological and behavioral indicators of pain in dairy cattle. Holstein cows were enrolled in a field study following LDA surgery. Surgery was performed using the standing right flank (RF) approach or the paramedian (PARA) approach. Using a triple-blind randomized trial, each animal was assigned to receive either 3mg of ketoprofen/kg of body weight or saline (the equivalent volume) by intramuscular injection immediately following surgery and 24h postoperatively. Physiological parameters (heart rate, respiration rate, and rumen motility), blood ß-hydroxybutyrate (BHBA) levels, and an assessment of cow attitude were measured on the day of surgery, and at 2 follow-up visits (visit 1=3 ± 0.9 d and visit 2=9 ± 1.2 d postsurgery; n=175). Milk production and culling were recorded for all cows enrolled in the study. Producers assessed their cows' attitudes and appetites daily for the first 3 d following surgery. A subset of cows (n=37) were fitted on the day of surgery with a 3-axis accelerometer on the hind leg to assess lying behavior. Continuous and binary outcome data were analyzed using multivariable mixed linear and mixed logistic models, respectively, with cow modeled as a random effect. Ketoprofen did not alter the physiological measures, BHBA levels, or behavioral outcomes measured. Cows subjected to RF surgery had longer lying times [model coefficient ß=228.9 min; 95% confidence interval (CI): 122.2 to 335.6] in the first 3 d following surgery, and lower heart rates (ß=-9.4 beats/min; 95% CI: -12 to -6.9 beats/min) at the follow-up visits, compared with animals that underwent PARA surgery. Regardless of surgical procedure, BHBA decreased from surgery day to visit 1 (ß=-1.9 mmol/L; 95% CI: -2.1 to -1.7) and visit 2 (ß=-2.0 mmol/L; 95% CI: -0.2.2 to -1.8). Producer reports indicated that animals that received ketoprofen were more likely to begin eating when provided fresh feed during the first 3 d following surgery compared with those that received saline (odds ratio=4.8; 95% CI: 0.97 to 23.8). These results indicate that PARA surgery may be more painful relative to lying down than the RF approach. The apparent differences in appetite or attitude in cows that received ketoprofen reported by producers warrant further investigation.

Effects of meloxicam on milk production, behavior, and feed intake in dairy cows following assisted calving.

Parturition is a necessary event for production in dairy cattle, and assistance at calving is common. There is limited use of nonsteroidal antiinflammatory drugs for the alleviation of calving pain and a paucity of research on the effects of these drugs on postpartum health and performance. This randomized triple blind clinical trial involved Holstein cows (n=42) and heifers (n=61) that experienced an assisted parturition. These animals received either 1 injection of meloxicam (0.5mg/kg of body weight) or placebo subcutaneously 24h following calving. Outcome measures included dry matter intake (DMI) and milk production for the first 14d in milk, blood metabolites sampled over 12d, health events for the first 60d in milk, as well as lying and feeding behavior 24h following injection. Continuous data were analyzed using multivariable regression models. Binary outcomes were analyzed using a mixed logistic model with cow modeled using a random intercept. This study failed to show any significant effects of treatment on DMI, milk production, blood metabolites, or health events. A possible explanation for the lack of treatment differences could be that the meloxicam was administered too late after calving. Meloxicam increased feeding time as well as bunk visit frequency in the 24h following injection. Regardless of treatment, animals that had retained fetal membranes produced less milk and had higher serum haptoglobin concentrations. Future research is warranted to examine the effects of antiinflammatory drugs administered closer to the time of calving on health and production.

Short communication: a comparison of 2 nonsteroidal antiinflammatory drugs following the first stage of a 2-stage fistulation surgery in dry dairy cows.

Postoperative pain and its management following fistulation surgery in cattle are poorly understood. The purpose of this study was to compare 2 nonsteroidal antiinflammatory drugs (NSAID) as potential postoperative pain management treatments following the first stage of a 2-stage fistulation surgery. A randomized complete block design trial was conducted in dry Holstein cows (n=10) following fistulation surgery. Ketoprofen (3mg/kg of body weight i.m.) was administered on the day of surgery and 24 h later, whereas meloxicam (0.5 mg/kg of body weight s.c.) was administered once only on the day of surgery. Outcomes evaluated at 0, 2, 9, 24, 26, and 33 h postsurgery were heart rate, respiration rate, rectal temperature, and infrared temperature around the surgical site. Outcomes evaluated on the day of surgery and d 1 following surgery and compared with the average for the 4d before surgery were lying activity (total lying time, total time spent lying on the left side, and percentage of time lying on the left side) and feed intake. A difference was observed in dry matter intake on d 1 but this effect was not different on d 0 compared with presurgical averages. A difference was observed in time spent lying on the left side and a difference was observed in heart rate following the first stage of fistulation surgery compared with presurgical averages. The infrared temperature readings around the surgical site were significantly greater in the hours following surgery compared with presurgical averages. The respiration rate increased over time after 24h postsurgery compared with presurgical values. Although it was clear that the surgery is painful, the drug effects were more difficult to explain. On d 0 and 1, the meloxicam-treated cows ate 3 kg more but spent 101 min/d less time lying on their left side compared with ketoprofen-treated cows. The first stage of a 2-stage fistulation surgery was considered painful based on changes in heart rate, respiration rate, infrared temperature readings, dry matter intake, and time spent lying on the left side. It is clear that left flank surgery is painful and that NSAID can improve outcomes associated with that pain, but we cannot make recommendations as to which NSAID to choose based on these results.

Opioid use after outpatient elective general surgery: quantifying the burden of persistent use.

Purpose: Surgery is a major risk factor for chronic opioid use among patients who had not recently been prescribed opioids. This study identifies the rate of, and risk factors for, persistent opioid use following laparoscopic cholecystectomy and open inguinal hernia repair in patients not recently prescribed opioids. Methods: This retrospective population-based cohort study included all patients who had not been prescribed opioids in the 6 months prior to undergoing open inguinal hernia repair or laparoscopic cholecystectomy from January 2013 to July 2016 in Ontario. Opioid prescription was identified from the provincial Narcotics Monitoring System and data were obtained from the Institute for Clinical Evaluative Sciences. The primary outcome was persistent opioid use after surgery (3, 6, 9 and 12 months). Associated risk factors and prescribing patterns were also examined. Results: Among the 90,326 patients in the study cohort, 80% filled an opioid prescription after surgery, with 11%, 9%, 5% and 1% filling a prescription at 3, 6, 9 and 12 months, respectively. Significant variability was identified in the type of opioid prescribed (41% codeine, 31% oxycodone, 18% tramadol) and in regional prescribing patterns (mean prescription/region range, 135-225 oral morphine equivalents). Predictors of continued opioid use included age, female gender, lower income quintile and being operated on by less experienced surgeons. Conclusion: Most patients who undergo elective cholecystectomy and hernia repair will fill a prescription for an opioid after surgery, and many will continue to fill opioid prescriptions for considerably longer than clinically anticipated. There is important variability in opioid type, regional prescribing patterns and risk factors that identify strategic targets to reduce the opioid burden in this patient population.