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.

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.

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.

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.

Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy.

BACKGROUND: Breast conservation therapy (BCT) is an oncologically equivalent and cosmetically preferable alternative to mastectomy for most early-stage breast cancers. The number of operations required to complete the surgical phase of therapy with BCT has not been widely reported. METHODS: From our institutional tumor registry, we reviewed the records of all patients receiving primary surgical therapy for breast cancer from January 1, 1998, to June 30, 2002. There were 204 patients with 210 breast cancers in the cohort. These cancers were initially managed with either BCT (n = 150) or mastectomy (modified radical mastectomy or total mastectomy with sentinel lymph node biopsy) (n = 60). We compared the percentages of patients in each group who required additional surgeries to obtain clear margins, manage axillary disease, or otherwise complete the surgical phase of therapy. Patients with secondary surgery related to long-term local recurrence were excluded. RESULTS: Fifty-one percent of patients initially managed with BCT required additional surgery compared with 12% in the mastectomy group (P <0.05). Factors independently associated with multiple surgeries among all patients included management with BCT (odds ratio [OR] 5.4, P = 0.01) and positive margins at initial excision (OR 4.7, P <0.01). Significant independent predictors of positive margins included BCT (OR 11.9, P <0.01); disease stage (OR 6.7, P <0.01); submission of supplemental margins in addition to the main specimen (OR 2.8, P = 0.03); and positive nodes (OR 1.1, P = 0.04). Breast conservation was ultimately successful in 95% of patients who underwent BCT. CONCLUSIONS: Patients undergoing BCT may require multiple surgeries to reconcile successful breast conservation with sound oncologic resection.

A case-match analysis of failed prior bariatric procedures converted to resectional gastric bypass.

BACKGROUND: Failure to lose weight or intractable symptoms after bariatric surgery presents a complex diagnostic and management challenge. The outcome of a standardized surgical approach to this problem has not been well described. Conversion of failed bariatric procedures to a resectional gastric bypass (RGB) can achieve symptomatic relief and acceptable weight loss. METHODS: We reviewed all patients in a prospectively maintained database who underwent reoperative bariatric surgery over a 4-year period. Reoperative patients (RO) were case-matched (by age, body mass index, and comorbidities) in a 1:2 ratio with control patients undergoing an initial bariatric procedure (IN). RESULTS: Twenty-seven reoperative patients and 54 case-matched control patients were identified. Mean body mass index was 42 in the RO group versus 45 in the IN group (P = not significant). Indications for conversion were weight gain (89%), dysphagia/emesis (30%), esophagitis (19%), and marginal ulcer (7%). All patients in both groups underwent RGB (subtotal gastrectomy with Roux-Y gastrojejunostomy). Compared with IN patients, the RO patients had significantly longer operative times (420 versus 268 minutes), greater blood loss (650 versus 315 cc), longer time to oral intake (3.1 versus 2.2 days), and longer hospital stays (6.5 versus 4.7 days), all P <0.01. There were no deaths or anastomotic leaks in either group. Excess body weight lost at 6 months was 46% for RO versus 54% for IN (P = 0.02). One-year excess weight lost was 71% for RO versus 77% for IN (P = not significant). All RO patients achieved symptomatic relief, and no patient required further bariatric revision. There was significant improvement in weight-related comorbidity in each group. CONCLUSIONS: Conversion of failed bariatric procedures to RGB, although technically demanding, resulted in relief of presenting symptoms, significant 6-month and 1-year weight loss, and improvement of major comorbidities. Conversion of failed bariatric procedures to resectional gastric bypass can achieve results comparable with those of patients undergoing an initial bariatric procedure.

Predictive value of intraoperative touch preparation analysis of sentinel lymph nodes for axillary metastasis in breast cancer.

BACKGROUND: Accurate intraoperative diagnosis of axillary malignancy facilitates completion axillary lymph node dissection (ALND) at the time of initial surgery. The capability to address both the primary tumor and axillary disease in a single procedure offers several advantages. This study was designed to define the predictive value of intraoperative touch preparation analysis of sentinel lymph nodes for axillary metastasis in breast cancer and to evaluate the ability of the technique to facilitate accurate synchronous ALND. METHODS: A consecutive cohort of patients with breast cancer at an Army medical center underwent intraoperative touch preparation analysis of sentinel lymph nodes concordant with initial excision. Those found to have sentinel nodes positive by touch preparation analysis underwent ALND at the initial procedure. Patients with negative sentinel nodes by touch preparation analysis, but positive by final pathology, underwent subsequent ALND. Results of the touch preparation analysis were compared with the final pathology. RESULTS: Over a 16-month period, 71 consecutive patients with breast cancer underwent initial excision and touch preparation analysis of 162 sentinel lymph nodes. Final pathology confirmed axillary metastasis in 32% (23 of 71) of patients. Of these, intraoperative touch preparation analysis identified 48% (11 of 23). There were no false positives or unnecessary axillary dissections based upon touch preparation results. Per sentinel node, the positive predictive value was 100%, the sensitivity was 47%, and the specificity was 100%. On a per patient basis, the positive predictive value was 100%, and the sensitivity and specificity were 48% and 100%, respectively. CONCLUSIONS: Intraoperative touch preparation analysis is an effective adjunct to sentinel lymph node biopsy. In our series, it facilitated a definitive cancer operation at the time of initial surgery in nearly 50% of patients, and ensured that no patient underwent an unnecessary axillary dissection.

An institutional experience with laparoscopic gastric bypass complications seen in the first year compared with open gastric bypass complications during the same period.

BACKGROUND: Complication rates for laparoscopic bariatric surgery remain in evolution. METHODS: Single institution review of the initial year's experience with laparoscopic gastric bypass compared with open gastric bypass complications for the same period. RESULTS: There were 20 laparoscopic and 52 open gastric bypass procedures. Five laparoscopic patients had major complications. There were 4 anastomotic leaks. Nine open bypass patients had major complications, with 2 leaks. Leak rate was 20% for the laparoscopic group and 4% for the open group. All leaks in both groups led to substantial morbidity. There were two deaths, one in each group. The laparoscopic death was from postleak sepsis. CONCLUSIONS: Gastric bypass, whether done open or laparoscopically, has significant surgical risk. Complication profiles differed between the two groups. Anastomotic leaks were significantly more frequent in the laparoscopic group, probably related to the learning curve. There is a continued need for open surgery in many bariatric patients.