Efficacy and safety of extended duration to perioperative thromboprophylaxis with low molecular weight heparin on disease-free survival after surgical resection of colorectal cancer (PERIOP-01): multicentre, open label, randomised controlled trial.

OBJECTIVE: To determine the efficacy and safety of extended duration perioperative thromboprophylaxis by low molecular weight heparin when assessing disease-free survival in patients undergoing resection for colorectal cancer. DESIGN: Multicentre, open label, randomised controlled trial. SETTINGS: 12 hospitals in Quebec and Ontario, Canada, between 25 October 2011 and 31 December 2020. PARTICIPANTS: 614 adults (age ≥18 years) were eligible with pathologically confirmed invasive adenocarcinoma of the colon or rectum, no evidence of metastatic disease, a haemoglobin concentration of ≥8 g/dL, and were scheduled to undergo surgical resection. INTERVENTIONS: Random assignment to extended duration thromboprophylaxis using daily subcutaneous tinzaparin at 4500 IU, beginning at decision to operate and continuing for 56 days postoperatively, compared with in-patient postoperative thromboprophylaxis only. MAIN OUTCOME MEASURES: Primary outcome was disease-free survival at three years, defined as survival without locoregional recurrence, distant metastases, second primary (same cancer), second primary (other cancer), or death. Secondary outcomes included venous thromboembolism, postoperative major bleeding complications, and five year overall survival. Analyses were done in the intention-to-treat population. RESULTS: The trial stopped recruitment prematurely after the interim analysis for futility. The primary outcome occurred in 235 (77%) of 307 patients in the extended duration group and in 243 (79%) of 307 patients in the in-hospital thromboprophylaxis group (hazard ratio 1.1, 95% confidence interval 0.90 to 1.33; P=0.4). Postoperative venous thromboembolism occurred in five patients (2%) in the extended duration group and in four patients (1%) in the in-hospital thromboprophylaxis group (P=0.8). Major surgery related bleeding in the first postoperative week was reported in one person (<1%) in the extended duration and in six people (2%) in the in-hospital thromboprophylaxis group (P=0.1). No difference was noted for overall survival at five years in 272 (89%) patients in the extended duration group and 280 (91%) patients in the in-hospital thromboprophylaxis group (hazard ratio 1.12; 95% confidence interval 0.72 to 1.76; P=0.1). CONCLUSIONS: Extended duration to perioperative anticoagulation with tinzaparin did not improve disease-free survival or overall survival in patients with colorectal cancer undergoing surgical resection compared with in-patient postoperative thromboprophylaxis alone. The incidences of venous thromboembolism and postoperative major bleeding were low and similar between groups. TRIAL REGISTRATION: ClinicalTrials.gov NCT01455831.

Scandal mining: political nobodies and remediated visibility.

This article considers the 2015 federal election in Canada as the emergence of seemingly citizen-led practices whereby candidates' past missteps are unearthed and distributed through social and news media channels. On first pass, these resemble citizen-led engagements through digital media for potentially unmappable political goals, given the dispersed and either non-partisan or multi-partisan nature of these engagements. By bringing together journalistic accounts and social media coverage alongside current scholarship on citizenship and visibility, this case study traces the possibility of political accountability and the political weaponisation of mediated visibility through the targeted extraction of candidate details from dispersed profiles, communities and databases.

Plastic freezer bags: a cost-effective method to protect extraction sites in laparoscopic colorectal procedures?

PURPOSE: To review surgical-site infection (SSI) and retrieval-site tumor recurrence rates in laparoscopic colorectal procedures when using a plastic freezer bag as a wound protector. METHODS: Laparoscopic colorectal procedures where a plastic freezer bag used as a wound protector at the extraction site were reviewed between 1991 and 2008 from a prospectively collected database. χ test was used to compare SSI and tumor recurrence rates between groups. Costing data were obtained from the operating room supplies department. RESULTS: A total of 936 cases with 51 (5.45%) surgical-site infections were identified. SSI rates did not differ when comparing groups based on demographic factors, diagnosis, or location of procedure. Retrieval-site tumor recurrence rate was 0.21% (1/474). Cost of plastic freezer bags including sterilization ranged from $0.25 to $3. CONCLUSIONS: Plastic freezer bags as wound protectors in laparoscopic colorectal procedures are cost effective and have SSI and retrieval-site tumor recurrence rates that compare favorably to published data.

Surgical residency training and international volunteerism: a national survey of residents from 2 surgical specialties.

BACKGROUND: Many low- and middle-income countries (LMICs) lack basic surgical resources, resulting in avoidable disability and mortality. Recently, residents in surgical training programs have shown increasing interest in overseas elective experiences to assist surgical programs in LMICs. The purpose of this study was to survey Canadian surgical residents about their interest in international volunteerism. METHODS: We sent a web-based survey to all general and orthopedic surgery residents enrolled in surgical training programs in Canada. The survey assessed residents' interests, attitudes and motivations, and perceived barriers and aids with respect to international volunteerism. RESULTS: In all, 361 residents completed the survey for a response rate of 38.0%. Half of the respondents indicated that the availability of an international surgery elective would have positively influenced their selection of a residency program. Excluding the 18 residents who had volunteered during residency, 63.8% of the remaining residents confirmed an interest in international volunteering with "contributing to an important cause," "teaching" and "tourism/cultural enhancement" as the leading reasons for their interest. Perceived barriers included "lack of financial support" and "lack of available organized opportunities." All (100%) respondents who had done an international elective during residency confirmed that they would pursue such work in the future. CONCLUSION: Administrators of Canadian surgical programs should be aware of strong resident interest in global health care and accordingly develop opportunities by encouraging faculty mentorships and resources for global health teaching.

Laparoscopic colostomy reversal after a Hartmann procedure: a prospective series, literature review and an argument against laparotomy as the primary approach.

BACKGROUND: Open restoration of bowel continuity after a Hartmann procedure has been associated with significant morbidity, including anastomotic leak, incisional hernia, wound infections and inability to re-establish intestinal continuity. Few studies have examined the role of laparoscopy in performing a Hartmann reversal. The aim of this study was to review our laparoscopic Hartmann reversal (LHR) experience with an emphasis on intra- and postoperative adverse events. METHODS: A prospectively collected laparoscopic colorectal database involving 3 surgeons in 4 academic centres between 1991 and 2008 was reviewed. Factors evaluated were patient demographics, diagnosis, duration of surgery, intra- and postoperative complications, recovery of bowel function and length of stay in hospital. RESULTS: Twenty-eight consecutive patients (13 men, 15 women) with a mean age of 61.1 (standard deviation [SD] 15.3) years and a mean weight of 72.3 (SD 20.1) kg underwent LHR. The diagnosis at initial surgery was complicated diverticulitis in 19 patients (67.9%), cancer in 6 patients (21.4%) and "other" in 3 patients (10.7%). The median duration of surgery was 166.2 (SD 74.4) minutes. There were no conversions. There was 1 major intraoperative complication (bleeding; 3.6%). There were 3 postoperative complications (10.7%): 1 abscess, 1 prolonged ileus and 1 wound hematoma. Only 1 patient with an abscess required readmission. There were no observed clinical anastomotic leaks. All patients underwent successful reanastomosis. The median time to return of bowel function was 4 (interquartile range [IQR] 3-4) days. The median length of stay in hospital was 5 (IQR 3-6) days. There was no mortality. CONCLUSION: Laparoscopic colostomy reversal after a Hartmann procedure is safe and feasible in experienced hands. It is associated with low morbidity, quick return of bowel function and short stay in hospital.

Outpatient thyroid surgery: should patients be discharged on the day of their procedures?

BACKGROUND: Outpatient surgery benefits patients and surgeons alike, as it is convenient, safe and cost-effective. We sought to assess the safety and feasibility of outpatient thyroid surgery (OTS) at an ambulatory site affiliated with a teaching hospital. METHODS: We performed a retrospective chart review of patients who underwent hemithyroidectomy, subtotal thyroidectomy, total thyroidectomy or completion thyroidectomy between 2002 and 2004 at the Riverside campus of The Ottawa Hospital. We analyzed patient outcomes based on hospital admission and readmission rates as well as complication rates. RESULTS: Two hundred and thirty-two patients met our inclusion criteria. Most patients were women (84%) with a mean age of 47 years. Of these patients, 43 had total thyroidectomies, 75 had subtotal thyroidectomies, 42 had left hemithyroidectomies, 57 had right hemithyroidectomies and 18 had completion thyroidectomies; 26% of these procedures were performed to treat cancer. Other pathologies included multinodular goitre (37%), adenoma (21%), nodular hyperplasia (12%) and Hashimoto thyroiditis (4%). The mean duration of surgery was 87 (range 50-150) minutes. No patients died or underwent reoperation. Complications included hypocalcaemia in 6 patients, hematoma in 1 patient, vocal cord injury in 1 patient and wound infection in 2 patients. All patients but 1 were discharged within 10 hours of surgery; the hospital admission rate was 0.4%. Four patients were readmitted within 1 week of surgery (2 for hypocalcemia, 1 for wound infection and 1 for pain control). CONCLUSION: Outpatient thyroid surgery is safe and is associated with a low complication rate.

Laparoscopic repair of paraesophageal hernias: a Canadian experience.

BACKGROUND: The surgical approach to paraesophageal hernias (PEH) has changed with the advent of laparoscopic techniques. Variation in both perioperative outcomes and hernia recurrence rates are reported in the literature. We sought to evaluate the short- and intermediate-term outcomes with laparoscopic PEH repair. METHODS: We performed a retrospective review of patients having laparoscopic repair of PEH between June 1998 and September 2002. We included patients with more than 120 days of follow-up. RESULTS: A total of 58 patients with a mean age of 60.4 (standard deviation [SD] 15.0) years had a laparoscopic procedure to repair a primary PEH, as well as adequate follow-up, during the study period. The types of PEH included type II (n = 13), III (n = 44) and IV (n = 1). The most common symptoms were epigastric pain (57%), dysphagia (40%), heartburn (31%) and vomiting (28%). Associated procedures included 56 (96%) Nissen fundoplications and 2 (4%) gastropexies. We closed all crural defects either with or without pledgets, and 2 patients required the use of mesh. There was 1 conversion to open surgery owing to intraoperative bleeding secondary to a consumptive coagulopathy; we observed no other major intraoperative emergencies. Minor or major complications occurred in 15 patients (26%). Late postoperative complications included 1 umbilical hernia. The mean length of stay in hospital was 3.8 (SD 2.5) days. After surgery, 19 patients were completely asymptomatic, and the majority of the remaining patients (83%) described marked symptom improvement. Upper gastrointestinal series performed in symptomatic patients in the postoperative setting identified 5 recurrent paraesophageal hernias (8.6%) and 5 small sliding hernias (9%). CONCLUSION: Laparoscopic repair of PEH is associated with improved long-term symptom relief, low morbidity and acceptable recurrence rates when performed in an experienced centre.

The use of endoscopic hemoclips for postoperative anastomotic bleeding.

With the availability of endoscopy and its inherent use as a diagnostic and therapeutic modality, many surgeons and gastroenterologists are able to use this tool to remedy a wide range of gastrointestinal pathologies. The literature is replete with anecdotal endoscopic therapeutic strategies ranging from epinephrine injection, to use of cautery or argon plasma coagulation. This case report highlights the use of endoscopic hemoclips which were successfully applied in the acute postoperative period for a bleeding vessel at a fresh anastomotic site. The article allows for a brief discussion of plausible endoscopic treatment strategies available to the surgeon faced with a similar situation.

Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin.

BACKGROUND: Surgical sphincterotomy for chronic anal fissure can cause fecal incontinence. This has led to the investigation of nonsurgical treatment options that avoid permanent damage to the internal anal sphincter. METHODS: We conducted a retrospective, ongoing chart review with telephone follow-up of 88 patients treated for chronic anal fissure between November 1996 and December 2002. During the first half of the study period, patients were treated with topical nitroglycerin and pneumatic dilatation. With the availability of new therapies in June 1999, subsequent patients received topical nifedipine and botulinum toxin injections (30-100 units). Lateral anal sphincterotomy was reserved for patients who failed medical treatment. RESULTS: In 98% of patients the fissure healed with conservative nonsurgical treatment. The combination of nifedipine and botulinum toxin was superior to nitroglycerin and pneumatic dilatation with respect to both healing (94% v. 71%, p < 0.05) and recurrence rate (2% v. 27%, p < 0.01). There was no statistical difference between the number of dilatations and botulinum toxin injections needed to achieve healing. Three patients who received botulinum toxin reported mild transient flatus incontinence. At an average telephone follow-up of 27 months, 92% of patients reported having no pain or only mild occasional pain with bowel movements. CONCLUSIONS: Chronic anal fissures can be simply and effectively treated medically without the risk of incontinence associated with sphincterotomy. Topical nifedipine and botulinum toxin injections are an excellent combination, associated with a low recurrence rate and minimal side effects.