Stemming the Tide of Opioid Addiction-Dramatic Reductions in Postoperative Opioid Requirements Through Preoperative Education and a Standardized Analgesic Regimen.

INTRODUCTION: Surgery is a known gateway to opioid use that may result in long-term morbidity. Given the paucity of evidence regarding the appropriate amount of postoperative opioid analgesia and variable prescribing education, we investigated prescribing habits before and after institution of a multimodal postoperative pain management protocol. MATERIALS AND METHODS: Laparoscopic appendectomies, laparoscopic cholecystectomies, inguinal hernia repairs, and umbilical hernia repairs performed at a tertiary military medical center from 01 October 2016 until 30 September 2017 were examined. Prescriptions provided at discharge, oral morphine equivalents (OME), repeat prescriptions, and demographic data were obtained. A pain management regimen emphasizing nonopioid analgesics was then formulated and implemented with patient education about expected postoperative outcomes. After implementation, procedures performed from 01 November 2017 until 28 February 2018 were then examined and analyzed. Additionally, a patient satisfaction survey was provided focusing on efficacy of postoperative pain control. RESULTS: Preprotocol, 559 patients met inclusion criteria. About 97.5% were provided an opioid prescription, but prescriptions varied widely (256 OME, standard deviation [SD] 109). Acetaminophen was prescribed often (89.5%), but nonsteroidal anti-inflammatory drug (NSAID) prescriptions were rare (14.7%). About 6.1% of patients required repeat opioid prescriptions. After implementation, 181 patients met inclusion criteria. Initial opioid prescriptions decreased 69.8% (77 OME, SD 35; P < 0.001), while repeat opioid prescriptions remained statistically unchanged (2.79%; P = 0.122). Acetaminophen prescribing rose to 96.7% (P = 0.002), and NSAID utilization increased to 71.0% (P < 0.001). Postoperative survey data were obtained in 75 patients (41.9%). About 68% stated that they did not use all of the opioids prescribed and 81% endorsed excellent or good pain control throughout their postoperative course. CONCLUSIONS: Appropriate preoperative counseling and utilization of nonopioid analgesics can dramatically reduce opioid use while maintaining high patient satisfaction. Patient-reported data suggest that even greater reductions may be possible.

The Halifax Explosion a century later: Lessons for our time.

A brief historical account of the Halifax Explosion, one of North America's greatest mass urban trauma casualty events of the 20th century. This disaster, in Halifax, Nova Scotia, was the result of the cataclysmic explosion of a fully loaded World War I munitions ship on the densely waterfront of that city, resulting in nearly 2000 fatalities and 9000 injured. It remains a case study in response to disasters which overwhelm local medical capabilities.

Lloyd Nyhus and Rene Stoppa: preperitoneal inguinal pioneers.

A brief history of the seminal contributions of Stoppa and Nyhus to inguinal hernia surgery.

Routine intraoperative leak testing for sleeve gastrectomy: is the leak test full of hot air?

BACKGROUND: Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 0% to 8%. Many surgeons routinely test the staple line with an intraoperative leak test (IOLT), but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak. METHODS: Retrospective review of all SGs performed over a 7-year period was conducted. Cases were grouped by whether an IOLT was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed. RESULTS: Five hundred forty-two SGs were performed between 2007 and 2014. Thirteen patients (2.4%) developed a postop staple line leak. The majority of patients (n = 494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. There was a trend, although not significant, to increase leak rates when a routine IOLT was performed vs no routine IOLT (2.6% vs 0%, P = .6). CONCLUSIONS: The performance of routine IOLT after SG provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.

The way we were: surgical practice at the dawn of the North Pacific Surgical Association.

The North Pacific Surgical Association Historian's centennial lecture, with review of the geographic challenges for members of this society at the time of its founding and selected insights into surgical practices and philosophies of a century ago.

The life and legacy of William T. Bovie.

This Historian's Address, presented at the North Pacific Surgical Association 2012 meeting, held in Spokane, Washington, on November 9, 2012, briefly reviews the life and surgical contributions of the inventor William T. Bovie and his collaboration with Dr Harvey Cushing, which led to the widespread acceptance of surgical electrocautery for dissection and hemostasis.

Pressure tolerance of newly constructed staple lines in sleeve gastrectomy and duodenal switch.

BACKGROUND: Many bariatric surgeons elect to pressure test the newly constructed staple lines in sleeve gastrectomy and duodenal switch procedures as a means of intraoperatively detecting leaks. The pressure tolerance of these fresh staple lines has not been well studied in a clinical setting. METHODS: This is a retrospective institutional review board-approved study that analyzed resected stomachs immediately after resection during a bariatric operation performed using sleeve gastrectomy or biliopancreatic diversion with duodenal switch. Resected stomachs were connected to a normal saline infusion and manometric pressure device for determining the maximum stomach capacity, the leak pressure, and the location of the first leak. RESULTS: Thirty patients (9 underwent biliopancreatic diversion with duodenal switch and 21 underwent sleeve gastrectomy) met the inclusion criteria (mean age of 44.7 years, 63.3% female) with a mean body mass index of 44.1 that was higher with biliopancreatic diversion (51.3 vs 41.0, P = .001) and a mean weight loss of 83 lb (a body mass index decrease of 13.4; median follow-up, 307 days). The leak volume of the resected stomach averaged 1,478 mL (range 1,100 to 2,200) with an average pressure of 25.6 cm H2O (range 12 to 60). The volume and leak pressures were equivalent despite the operative approach (P = .79 and .32, respectively), and there was no difference in the location of the leak (staple line or intrinsic stomach) based on volume or pressure (P = .246 and .131, respectively), with 50% of leaks occurring on the staple lines. CONCLUSIONS: The fresh staple lines in vertical sleeve gastrectomy and duodenal switch show burst strength well in excess of any intragastric pressures likely to be created by brief intraoperative leak checks via air instilled by an orogastric tube or intraoperative endoscopy. Leak testing is not likely to create iatrogenic damage to properly constructed fresh staple lines in these procedures.

Dr Robert McKechnie: Vancouver's pioneer surgeon and a patron of British Columbia sports & education.

Robert E. McKechnie, M.D.C.M. (1861-1944), was a distinguished graduate of McGill Medical School and a pioneer in the early days of surgery in Vancouver, Canada. He was a long-standing Canadian leader in both clinical and academic surgery. In addition, he played an important role in the founding of the University of British Columbia. He also commissioned an important challenge cup for the British Columbia rugby championship team in the same time and place as the establishment of hockey's Stanley Cup.

The duodenal switch for morbid obesity: modification of cardiovascular risk markers compared with standard bariatric surgeries.

BACKGROUND: Obesity is associated with cardiovascular risk factors such as lipid levels and increased levels of C-reactive peptide (CRP). We hypothesized that duodenal switch (DS) would show equivalent or superior risk reduction compared with standard bariatric surgeries. METHODS: Patients underwent DS, sleeve gastrectomy (SG), or gastric bypass (GB) over a 2-year period. Body mass index (BMI), lipid panel, and CRP were measured preoperatively and then 3, 6, and 12 months postoperatively. RESULTS: A total of 130 patients were identified; 42 underwent DS, 40 underwent SG, and 48 underwent GB. All groups had similar sex and comorbidity profiles, but the mean preoperative BMI was greatest in the DS group (mean = 52). At all intervals weight loss was greater in the DS group (P < .01), with a final BMI of 31 for the DS group, 31 for the SG group, and 28 for the GB group. Cholesterol and low-density lipoprotein showed significantly greater improvement at all time points with DS compared with SG and GB (P < .01). Baseline CRP levels among DS patients were double that of SG and GB, but rapidly declined to equivalent levels by 3 months and normalized in 79%. CONCLUSIONS: The DS procedure resulted in a superior reduction in cardiovascular and proinflammatory risk markers compared with GB and SG.

Early results after introduction of biliopancreatic diversion/duodenal switch at a military bariatric center.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD/DS) is one of the most effective procedures in terms of weight loss and durability. It is also one of the most complex and highest risk bariatric procedures. The authors report their initial experience with BPD/DS. METHODS: A retrospective review of all patients undergoing BPD/DS was performed, including a descriptive analysis of demographics, operative data, complications, and outcomes. Results were also compared with those among a group of 100 patients undergoing laparoscopic gastric bypass (LGB). RESULTS: Forty-three patients were identified. Mean preoperative body mass index was 52 kg/m(2), and 56% of patients had body mass indexes > 50 kg/m(2). Twenty (47%) were attempted laparoscopically, with 5 (25%) requiring conversion to open approach. Overall mean operative time was 269 minutes, with no significant difference between laparoscopic (256 minutes) and open (280 minutes). No major intraoperative complications occurred. Major postoperative complications included 4 gastric sleeve leaks, 2 small bowel obstructions, 1 intra-abdominal hemorrhage, and 1 duodenal stump leak. There was 1 death. Mean percentage excess body weight loss was 85% at 1 year. No patients developed severe malabsorptive symptoms or evidence of protein malnutrition. BPD/DS was associated with longer operative times and higher complication rates (P < .05 for both) compared with LGB but had significantly greater weight loss at 1 year (P < .05). CONCLUSION: BPD/DS is a complex procedure associated with increased operative times, increased risk for conversion from laparoscopic to open approach, and higher postoperative complication rates. However, it results in significantly greater weight loss than LGB without major adverse nutritional impact.

Resectional gastric bypass outcomes in active duty soldiers: a retrospective review.

BACKGROUND: As in civilian life, some active duty service members have developed severe obesity that is refractory to diet alteration and exercise. In addition to controlling obesity, surgical weight control measures in an active duty population must consider the effect of the postbariatric state on a service member's ability to continue to be deployable to a war zone or other austere military assignment. We report our experience with such patients undergoing open resectional gastric bypass. METHODS: We retrospectively reviewed the perioperative and long-term outcomes of 33 active duty service members who had undergone open gastric bypass by the same surgical team at a single institution during a 30-month period. Data were collected by chart review and questionnaires. Descriptive and inferential analyses were performed using Statistical Package for Social Sciences, version 14.0. RESULTS: The questionnaires were returned by 27 patients (13 women and 14 men). The mean age at surgery was 34.2 years (range 24-51). The mean follow-up was 218 weeks (range 162-369). The mean preoperative body mass index was 40.6 kg/m(2) (range 34.0-49.4). The mean postoperative BMI was 25.6 kg/m(2) (range 19-34.7). Using the Bariatric Analysis and Reporting Outcome System outcome criteria for these 27 patients, the results were fair for 4 patients (15%), good for 9 (33%), very good for 12 (44%), and excellent for 2 (7%). No patients had treatment failure according to the Bariatric Analysis and Reporting Outcome System criteria. Also, 5 patients who had previously been nonpromotable because of their weight were reclassified as promotable after the results of the bariatric intervention. Of the 27 patients, all but 3 maintained or achieved deployable status after surgical recovery. CONCLUSION: As in civilian populations, bariatric surgery improves the quality of life of active duty service members who have failed nonoperative means of obesity control. Most service members who undergo bariatric intervention are able to successfully deploy to war zones without adverse effects on their military performance and retain or improve their competitiveness for career promotion.

Prophylactic mesh to prevent incisional hernia: a note of caution.

BACKGROUND: Ventral hernia is a common complication of open Roux-en-Y gastric bypass (RYGB). The aim of this study was to determine whether prophylactic mesh placement during RYGB would reduce the incidence of postoperative hernias. METHODS: Obese patients undergoing RYGB by a single surgeon had prosthetic mesh placed in a subfascial location at the conclusion of the procedure. The incidences of recurrent hernia and morbidity associated with the placement of mesh were assessed. RESULTS: Sixteen patients underwent RYGB with prophylactic mesh placement over 6 months. The average preoperative body mass index was 46.6 kg/m(2). Half of the patients were diabetics. None were smokers. During mean follow-up of 6 months, 4 patients (25%) required mesh excision, 3 for infection and 1 for a persistently symptomatic seroma. One patient was explanted incidentally in the course of reexploration for intractable nausea and vomiting. Another developed an incisional hernia despite prophylactic mesh. CONCLUSIONS: In the investigators' experience, the use of prophylactic new-generation mesh at the time of open RYGB led to an unacceptable rate of local complications. They caution against this technique in patients undergoing open RYGB.

A remembrance of Victoria and the Canadian Army Medical Corps in the Great War.

The North Pacific Surgical Association first met in Victoria in December, 1917, in the midst of World War I, or as it was known then, the Great War. On all sides, the toll in human life was staggering. Canada alone lost more than 60,000 men in the war. Our Association now returns to Victoria as the very last survivors of that generation pass into history. We honor the great sacrifice of the Canadian Army, recall the horrific conditions they endured, and honor the doctors and nurses who attended the countless wounded through the experiences of a Canadian surgeon from Calgary, Dr. Harold McGill, who served for 3 years in the thick of action on the Western Front.