Search

Copyright of Canadian Journal of Surgery is the property of CMA Impact Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Severe complicated intra-abdominal sepsis (SCIAS) has an increasing incidence with mortality rates over 80% in some settings. Mortality typically results from disruption of the gastrointestinal tract, progressive and self-perpetuating bio-mediator generation, systemic inflammation, and multiple organ failure. A further therapeutic option may be open abdomen (OA) management with negative peritoneal pressure therapy (NPPT) to remove inflammatory ascites and attenuate the systemic damage from SCIAS, although there are definite risks of leaving the abdomen open whenever it might possibly be closed. This potential therapeutic paradigm is the rationale being assessed in the Closed Or Open after Laparotomy (COOL trial) (https://clinicaltrials.gov/ct2/show/NCT03163095). Initially, the COOL trial received Industry sponsorship; however, this funding mandated the use of a specific trademarked and expensive NPPT device in half of the patients allocated to the intervention (open) arm. In August 2022, the 3 M/Acelity Corporation without consultation but within the terms of the contract canceled the financial support of the trial. Although creating financial difficulty, there is now no restriction on specific NPPT devices and removing a cost-prohibitive intervention creates an opportunity to expand the COOL trial to a truly global basis. This document describes the evolution of the COOL trial, with a focus on future opportunities for global growth of the study. Methods: The COOL trial is the largest prospective randomized controlled trial examining the random allocation of SCIAS patients intra-operatively to either formal closure of the fascia or the use of the OA with an application of an NPPT dressing. Patients are eligible if they have free uncontained intraperitoneal contamination and physiologic derangements exemplified by septic shock OR severely adverse predicted clinical outcomes. The primary outcome is intended to definitively inform global practice by conclusively evaluating 90-day survival. Initial recruitment has been lower than hoped but satisfactory, and the COOL steering committee and trial investigators intend with increased global support to continue enrollment until recruitment ensures a definitive answer. Discussion: OA is mandated in many cases of SCIAS such as the risk of abdominal compartment syndrome associated with closure, or a planned second look as for example part of "damage control"; however, improved source control (locally and systemically) is the most uncertain indication for an OA. The COOL trial seeks to expand potential sites and proceed with the evaluation of NPPT agnostic to device, to properly examine the hypothesis that this treatment attenuates systemic damage and improves survival. This approach will not affect internal validity and should improve the external validity of any observed results of the intervention. Trial registration: National Institutes of Health (https://clinicaltrials.gov/ct2/show/NCT03163095). [ABSTRACT FROM AUTHOR]

Background: The risk of death after a postoperative complication - known as failure to rescue (FTR) - has been proposed to be superior to traditional benchmarking outcomes, such as complication and mortality rates, as a measure of system quality. The purpose of this study was to identify the current FTR rate in emergency general surgery (EGS) centres across Canada. We hypothesized that substantial variability exists in FTR rates across centres.Methods: In this multicentre retrospective cohort study, we performed a secondary analysis of data from a previous study designed to evaluate operative intervention for nonappendiceal, nonbiliary disease by 6 EGS services across Canada (1 in British Columbia, 1 in Alberta, 3 in Ontario and 1 in Nova Scotia). Patients underwent surgery between Jan. 1 and Dec. 31, 2014. We conducted univariate analyses to compare patients with and without complications. We performed a sensitivity analysis examining the mortality rate after serious complications (Clavien-Dindo score 3 or 4) that required a surgical intervention or specialized care (e.g., admission to intensive care unit).Results: A total of 2595 patients were included in the study cohort. Of the 206 patients who died within 30 days, 145 (70.4%) experienced a complication before their death. Overall, the mortality rate after any surgical complication (i.e., FTR) was 16.0%. Ranking of sites by the traditional outcomes of complication and mortality rates differed from the ranking when FTR rate was included in the assessment.Conclusion: There was variability in FTR rates across EGS services in Canada, which suggests that there is opportunity for ongoing quality-improvement efforts. This study provides FTR benchmarking data for Canadian EGS services. [ABSTRACT FROM AUTHOR]

Summary: Acute care surgery (ACS) is an area of surgical specialization within general surgery and a model for clinical care delivery that has proliferated over the last 2 decades. Models of ACS in Canada exist in both academic and community settings and are used to manage patients in need of emergency general surgery (EGS) care, with or without the provision of trauma care. The implementation of the ACS model has changed the landscape of patient care, surgical education and the workforce, providing an option for some general surgeons to exclude EGS care from their regular practice. The rise of ACS as a concentration of surgical skill and content expertise has resulted in the establishment of dedicated ACS fellowship training programs. This is a landmark in the evolution of general surgery, as well as a stepping stone on the path to improving patient care, surgical education and scholarly endeavour in this field. [ABSTRACT FROM AUTHOR]

While blunt trauma was the most common mechanism of injury among all patients, PD patients were found to have higher rates of penetrating injury than non-PD patients (17.9% v. 8.6%, p < 0.001) and were more commonly victims of assault (5.3% v. 2.1%, p < 0.001). To identify optimal practices for the care of these patients in our inclusive, provincial trauma system, we sought to determine if there were important differences in patient composition or outcomes among adult patients with isolated subdural hematomas admitted to a neurosurgical trauma centre (NSTC) versus those admitted to a level 3, non-neurosurgical trauma centre (non-NSTC). Embolization in nonsplenic trauma: outcomes at a Canadian trauma hospital Background Angiography and embolization for hemorrhage control is first-line treatment for solid organ and pelvic injuries in hemodynamically stable trauma patients. Blunt injuries were most common (144 patients [81.8%] had a blunt injury, 27 [15.3%] had a penetrating injury and 3 [1.7%] had a burn), with average Injury Severity Score 13 (1-45) and average length of stay 10.6 (SD 14.6) days. Motor vehicle crashes (MVCs) predominated (66 patients, 37.5%) followed by falls (33 patients, 18.8%), sport-related injuries (30 patients, 17.1%) and stabbings (17 patients, 9.7%). [Extracted from the article]

The rare (<2%) development of calcium deposits in soft tissue, known as dystrophic calcification (DC) with the use of Stimulan® (Biocomposites Ltd, Wilmington, NC) absorbable, calcium sulfate antibiotic beads (CSABs) in the setting of orthopedic surgery has previously been described. However, the use of CSAB in hernia repair is relatively novel and its association with the development of DC in this setting has not been previously reported. We describe a case where DC following abdominal wall reconstruction with CSAB was misinterpreted on CT imaging as an enteric fistula and almost resulted in an unnecessary emergency surgical procedure. [ABSTRACT FROM AUTHOR]

A 57-year-old male who presented with a recurrent ileostomy prolapse was successfully treated with the modified laparoscopic Sugarbaker procedure. This case demonstrates a novel application of the modified laparoscopic Sugarbaker procedure and provides an alternative option for the surgeon managing this challenging problem of recurrent stomal prolapse. [ABSTRACT FROM AUTHOR]

Background: Single-stage repair of incisional hernias in contaminated fields has a high rate of surgical site infection (30-42%) when biologic grafts are used for repair. In an attempt to decrease this risk, a novel graft incorporating gentamicin into a biologic extracellular matrix derived from porcine small intestine submucosa was developed.Methods: This prospective, multicenter, single-arm observational study was designed to determine the incidence of surgical site infection following implantation of the device into surgical fields characterized as CDC Class II, III, or IV.Results: Twenty-four patients were enrolled, with 42% contaminated and 25% dirty surgical fields. After 12 months, 5 patients experienced 6 surgical site infections (21%) with infection involving the graft in 2 patients (8%). No grafts were explanted.Conclusions: The incorporation of gentamicin into a porcine-derived biologic graft can be achieved with no noted gentamicin toxicity and a low rate of device infection for patients undergoing single-stage repair of ventral hernia in contaminated settings.Trial Registration: The study was registered March 27, 2015 at www.clinicaltrials.gov as NCT02401334. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Surgery is the property of CMA Impact Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Canadian Journal of Surgery is the property of CMA Impact Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Canadian Journal of Surgery is the property of CMA Impact Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Methylene blue (MB) has been used with some success as a treatment for the vasoplegia of vasopressor-refractory septic shock. The putative mechanism of action ofMBis the inhibition of endothelial nitric oxide within the microvasculature and improved responsiveness to endogenous catecholamines (norepinephrine (NE)). However, to date, no study has demonstrated the microcirculatory effect of methylene blue in septic shock. The objective of this randomized, controlled, animal study was to show, in an experimentally-induced, septic shock model in rats, the effects of MB and NE on global hemodynamics and the microcirculation. Mean arterial pressure (MAP) was drastically reduced following bacterial endotoxin (lipopolysaccharide, LPS) administration in animals not receiving vasopressors. Only the combination of NE +MB restored MAP to control levels by the end of the three hour experiment. Intravital microscopy of the microcirculation was performed in the terminal ileum in order to examine functional capillary density in intestinal muscle layers and the mucosa, as well as leukocyte activation in venules (rolling, adhesion to the endothelium). Untreated LPS animals showed a significant increase in leukocyte adhesion and a decrease in capillary perfusion in the intestinal microcirculation. In groups receiving NE or NE+MB, we observed a significant decrease in leukocyte adhesion and improved functional capillary density, indicating that microvasculature functionwas improved. This study suggests that methylene blue may be able to improve hemodynamics while preserving microvascular function in septic shock. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Surgery is the property of CMA Impact Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Tricyclic antidepressant (TCA) overdose is a leading cause of death among intentional overdoses. Intravenous lipid emulsion therapy is an emerging antidote for local anesthetic toxicity, and there is animal evidence that lipid therapy may be efficacious in TCA overdose. Furthermore, case reports in humans have described the use of lipid therapy to reverse the toxicity of other lipophilic drugs. Here we report a 25-year-old female presenting with coma and hemodynamic instability following intentional ingestion of amitriptyline. She had multiple episodes of pulseless wide-complex tachycardia despite conventional treatment with chest compressions, cardioversion, lidocaine, epinephrine, norepinephrine, magnesium sulphate, sodium bicarbonate, activated charcoal, and whole bowel irrigation. Twenty percent lipid emulsion was administered intravenously (an initial 150 mL bolus, followed by an infusion at 16 mL/h and a second bolus of 40 mL) over 39 hours (total dose 814 mL) yet resulted in no dramatic changes in hemodynamics or level of consciousness. However, there was a decrease in the frequency of wide-complex tachycardia during the lipid emulsion infusion and a recurrence of wide-complex tachycardia shortly after the infusion was stopped. The patient was discharged from the intensive care unit 11 days later with no lasting physiologic sequelae. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Anaesthesia / Journal Canadien d'Anesthésie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Lifestyle has been identified by numerous studies as the number one deterrent to pursuing a career in general surgery. This study tests the hypothesis that a better lifestyle during general surgery clerkship correlates with a higher application rate to general surgery. Canadian Residency Matching Service data from the past 10 years were used to identify institution-specific application rates to general surgery. Through a survey of all fourth-year medical students applying to general surgery in Canada and Canadian undergraduate surgery program directors, the lifestyle of each general surgery clerkship was described and given a score. Multiple descriptions of the clerkship structure were obtained for every school in Canada to reduce recall bias, with an average of 4 sources per program. One school stood out as the most prolific producer of general surgery applicants, with an average of 7.9% of the total class applying to general surgery each year. This represented 80% more general surgery applicants relative to the national average ( p < 0.05). Surprisingly, however, this institution also had the worst clerkship lifestyle score, having a higher call requirement, not sending their clerks home at noon post call, and placing a higher burden of responsibility on their clerks. This study suggests that a lifestyle-friendly surgical clerkship may not be necessary to increase recruitment into general surgery. [ABSTRACT FROM AUTHOR]