Variation in esophageal anastomosis technique-the role of collaborative learning.

Centralization of care has improved outcomes in esophagogastric (EG) cancer surgery. However, specialist surgical centers often work within clinical silos, with little transfer of knowledge and experience. Although variation exists in multiple dimensions of perioperative care, the differences in operative technique are rarely studied. An esophageal anastomosis workshop was held to identify areas of common and differing practice within the operative technique. Surgeons showed videos of their anastomosis technique by open and minimally invasive surgery. Each video was followed by a discussion. Surgeons from 10 different EG cancer centers attended. Eight key technical differences and learning points were identified and discussed: the optimum diameter of the gastric conduit; avoiding ischemia in the gastric conduit; minimizing esophageal trauma; the use of an esophageal mucosal collar; omental wrapping; intraoperative leak testing; ideal diameter of the circular stapler and the growing use of linear stapled anastomoses. The workshop received positive feedback from participants and on 2 years follow-up, 40% stated that they believed that the learning of tips and techniques during the workshop has contributed to lowering their anastomotic leak rate. Many differences exist in surgical technique. The reasons for, and crucially the significance of, these differences must be discussed and examined. Workshops provide a forum for peer-to-peer collaborative learning to reflect on one's own practice and improve surgical technique. These changes can, in turn, generate incremental improvements in patient care and postoperative outcomes.

Risk factors for milk off-flavours in dairy herds from Prince Edward Island, Canada.

A sudden increase in the incidence of milk off-flavours in bulk tank milk from Prince Edward Island (Canada) dairy farms in the late 1990s prompted an investigation of potential herd-level risk factors. A prospective case-control study was conducted from 2000 to 2002. Data on herd management were obtained by questionnaire and field investigation from all the 62 identified off-flavour positive farms (cases) and 62 loosely matched (for data-collection convenience) off-flavour negative farms (controls). Forty-three of the 62 cases (69%) of milk off-flavours identified during the study period were classified as "transmitted" (feed) off-flavours, and 9 (15%), 6 (10%), and 4 (6%) as "rancid", "oxidized" and "malty" off-flavours, respectively. Given this evidence and the relatively low incidence of other flavour defects in milk, only transmitted-flavour cases were considered in the analyses of risk factors. Poor air quality in the lactating cows' barn (OR = 40.8), using baled silage as the main forage (OR = 10.6), as well as feeding roughage before milking (OR = 253.3) or as a free choice (OR = 3.2) all were significantly (P < 0.05) associated with the incidence of transmitted flavours in bulk-tank milk. Clipping the hair on the cows' udder (OR = 0.07) and changing the bedding material more than once a day (OR = 0.12) were protective. The finding about feeding baled silage before milking has raised hypotheses about silage composition (in particular the off-flavour compounds or their precursors) and also about the process of silage making itself.