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For patients with unresectable colorectal liver metastases (uCRLM), regional therapies leverage the unique, dual blood supply to the liver; the hepatic artery is the main blood supply for liver tumors, whereas the portal vein supplies most normal hepatic parenchyma. Infusion of cancer therapies via the hepatic artery allows selective delivery to the tumors with relative sparing of normal liver tissue and little extrahepatic exposure, thus limiting systemic side effects. There is a paucity of randomized controlled trial evidence to inform the optimal integration of regional therapies into the management of CRLM. Hepatic arterial infusion pump (HAIP) chemotherapy has a potential survival benefit when used in the adjuvant setting after resection of CRLM. HAIP chemotherapy can be safely given with contemporary systemic therapies and is associated with a high objective response and rate of conversion to resectability in patients with uCRLM. Drug-eluting beads coated with irinotecan transarterial chemoembolization is associated with high objective response rates within the liver and has a well-established safety profile in patients with uCRLM. Transarterial radioembolization achieves high rates of response within the liver but is not associated with improvements in overall survival or quality of life in the first- or second-line setting for uCRLM. The best treatment approach is the one that most aligns with a given patients' values, preferences, and philosophy of care. In the first-line setting, HAIP could be offered to motivated patients who hope to achieve conversion to resectability. After progression on chemotherapy, HAIP, transarterial chemoembolization, and transarterial radioembolization are valuable treatment options to consider for patients with liver-limited or liver-predominant CRLM who seek to optimize response rates and regional control.

Surgical site infection is common after colorectal surgery and is associated with increased costs. Prophylactic negative pressure wound therapy has previously been shown to reduce surgical site infection compared with conventional dressings. However, negative pressure wound therapy application is met with hesitancy because of its additional cost.This study aims to determine whether the application of prophylactic negative pressure wound therapy after elective colorectal surgery is cost-effective.A cost-effectiveness analysis comparing prophylactic negative pressure wound therapy versus conventional dressing was completed using a Markov microsimulation model. A publicly funded single health care payer perspective was adopted across a lifetime horizon.This study was conducted using in-hospital elective colorectal surgery.The base case was an age-, sex-, and comorbidity-standardized patient undergoing open elective colorectal surgery.Negative pressure wound therapy was applied postoperatively over closed incisions.The primary outcomes of interest were the number of surgical site infections, total costs, and quality-adjusted life-years gained. Secondary outcomes included emergency department presentation, hospital readmission, nursing wound care utilization, fascial dehiscence, incisional hernia, and non-surgical site infection-related complications.We found that prophylactic negative pressure wound therapy, standardized to 1000 patients, prevented 51 surgical site infections, 3 fascial dehiscences, 10 incisional hernias, 22 emergency department presentations, and 6 hospital readmissions. This resulted in a total cost saving of $17,066 and 92.2 quality-adjusted life-years gained ($17.07 and 0.09 quality-adjusted life-years gained on average per patient). When the patients' risk of surgical site infections was greater than 3.2%, negative pressure wound therapy was a cost-effective strategy at a willingness to pay of $50,000/quality-adjusted life-years.We did not model for societal perspective, emergent presentations of incarcerated hernias, or complications with hernia repair. The results of this model are reliant on the published negative pressure wound therapy efficacy and may change when additional data arise.The use of negative pressure wound therapy is the dominant strategy with improved outcomes and reduced costs compared with conventional dressing in patients undergoing colorectal surgery, particularly in at-risk patients. See Video Abstract at http://links.lww.com/DCR/B782.ANTECEDENTES:La infección del sitio quirúrgico es común después de la cirugía colorrectal y se asocia con un aumento de los costos. Anteriormente se demostró que la terapia profiláctica con presión negativa reduce la infección del sitio quirúrgico en comparación con los apósitos convencionales. Sin embargo, el uso de la terapia de presión negativa se encuentra en dudas debido a su costo adicional.OBJETIVO:Determinar si la aplicación de la terapia profiláctic con presión negativa después de la cirugía colorrectal electiva es rentable.DISEÑO:Se completó un análisis de costo-efectividad comparando la terapia profiláctica con presión negativa versus apósito convencional utilizando un modelo de microsimulación de Markov. Se adoptó una perspectiva de pagador único de asistencia sanitaria financiada con fondos públicos a lo largo de toda la vida.AJUSTE:Cirugía colorrectal electiva intrahospitalaria.PACIENTES:El caso base fue un paciente estandarizado por edad, sexo y comorbilidad sometido a cirugía colorrectal abierta electiva.INTERVENCIÓN:Aplicación postoperatoria de terapia de presión negativa sobre incisiones cerradas.RESULTADOS PRINCIPALES:Los resultados primarios de interés fueron el número de infecciones del sitio quirúrgico, los costos totales y los años de vida ganados ajustados por calidad. Los resultados secundarios incluyeron presentación en la sala de emergencias, reingreso al hospital, la utilización del cuidado de heridas por enfermería, dehiscencia fascial, hernia incisional y complicaciones relacionadas con infecciones del sitio no quirúrgico.RESULTADOS:Estandarizado para 1,000 pacientes, encontramos que la terapia profiláctica con presión negativa previno 51 infecciones del sitio quirúrgico, 3 dehiscencias fasciales, 10 hernias incisionales, 22 presentaciones en la sala de emergencias y 6 reingresos al hospital. Esto resultó en un ahorro total de costos de $ 17.066 y 92.2 años de vida ganados ajustados por calidad ($ 17.07 y 0.09 años de vida ganados ajustados por calidad en promedio por paciente). Cuando el riesgo de infección del sitio quirúrgico de los pacientes era superior al 3,2%, la terapia de presión negativa era una estrategia rentable con una disposición a pagar de 50.000 dólares por años de vida ajustados por calidad.LIMITACIONES:No modelamos para la perspectiva social, presentaciones emergentes de hernias encarceladas o complicaciones con la reparación de hernias. Los resultados de este modelo dependen de la eficacia publicada de la terapia de presión negativa y pueden cambiar cuando surjan más datos.CONCLUSIONES:El uso de la terapia de presión negativa es la estrategia dominante con mejores resultados y costos reducidos en comparación con el apósito convencional en pacientes sometidos a cirugía colorrectal, particularmente en pacientes de riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B782. (Traducción- Dr. Francisco M. Abarca-Rendon).

Background Post-operative pancreatic fistula (POPF) is the most significant cause of morbidity following distal pancreatectomy. Hemopatch™ is a thin, bovine collagen-based hemostatic sealant. We hypothesized that application of Hemopatch™ to the pancreatic stump following distal pancreatectomy would decrease the incidence of clinically-significant POPF. Methods We conducted a prospective, single-arm, multicentre phase II study of application of Hemopatch™ to the pancreatic stump following distal pancreatectomy. The primary outcome was clinically-significant POPF within 90 days of surgery. A sample size of 52 patients was required to demonstrate a 50% relative reduction in Grade B/C POPF from a baseline incidence of 20%, with a type I error of 0.2 and power of 0.75. Secondary outcomes included incidence of POPF (all grades), 90-day mortality, 90-day morbidity, re-interventions, and length of stay. Results Adequate fixation Hemopatch™ to the pancreatic stump was successful in all cases. The rate of grade B/C POPF was 25% (95%CI: 14.0–39.0%). There was no significant difference in the incidence of grade B/C POPF compared to the historical baseline (p = 0.46). The 90-day incidence of Clavien–Dindo grade ≥3 complications was 26.9% (95%CI: 15.6–41.0%). Conclusion The use of Hemopatch™ was not associated with a decreased incidence of clinically-significant POPF compared to historical rates. (NCT03410914).

ImportanceDespite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood.ObjectiveTo define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics.Design, Setting, and ParticipantsPragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment.InterventionThe intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care).Main Outcomes and MeasuresThe primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program.ResultsThe trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, −13.0% [95% CI, −19.1% to −6.9%]; P P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, −6.3% [95% CI, −11.4% to −1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, −1.2% [95% CI, −3.1% to 0.7%]; P = .32).Conclusions and RelevanceIn participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy.Trial RegistrationClinicalTrials.gov Identifier: NCT03269994

Administration of chemotherapy to patients with colorectal liver metastases may result in disappearing liver metastases (DLM). This poses a therapeutic dilemma due to the uncertainty of true complete (pathological) response. We aimed to examine the diagnostic performance of imaging modalities in detecting true complete response in patients with DLM after chemotherapy. We performed a systematic search for articles assessing the diagnostic performance of imaging modalities in evaluating DLM following chemotherapy. True complete response was defined as 1-year recurrence-free survival in non-resected patients or complete pathological response on histologic examination in resected patients. We calculated the negative predictive value (NPV) for detecting true complete response of each imaging modality using a random effects model. Thirteen studies comprising 332 patients with at least one DLM were included. The number of DLMs after chemotherapy was 955 with computed tomography (CT), 104 with positron emission tomography (PET), 50 with intraoperative ultrasound (IOUS), 585 with magnetic resonance imaging (MRI), and 175 with contrast-enhanced IOUS (CEIOUS). Substantial variation in study design, patient characteristics, and imaging features was observed. Pooled NPV was 0.79 (95% confidence interval [CI] 0.53–0.96), 0.73 (95% CI 0.58–0.85), 0.54 (95% CI 0.37–0.7), 0.47 (95% CI 0.34–0.61), and 0.22 (95% CI 0.11–0.39) for CEIOUS, MRI, IOUS, CT, and PET, respectively. After chemotherapy, MRI or CEIOUS are the most accurate imaging modalities for assessment of DLM and should be used routinely in this context. Given the high NPV of these two modalities, surgical resection of visible CRLM is warranted if technically possible, even if DLM remain.

While the contemporary management of adhesive small bowel obstruction (SBO) often includes a trial of non-operative management (NOM), surgical dogma dictates urgent operative exploration in patients without previous abdominal surgery. This dogma has been challenged by recent evidence suggesting most obstructions in this population are adhesive in nature. The objectives of this review were to evaluate the feasibility of NOM in patients with SBO and no history of previous abdominal surgery, to examine the etiologies of SBO in this population, and to explore the rate of adverse events seen following NOM. Embase, Medline, Cochrane, and Google Scholar were searched from inception to September 24, 2019. Articles reporting on NOM for SBO in patients without previous abdominal surgery and without clinical or radiographic features necessitating an emergent operation were included. Data were combined to obtain a pooled proportion of patients discharged without operation following a trial of NOM. 6 studies reporting on a total of 272 patients were included. The pooled proportion of patients discharged following NOM was 49.5% (95% CI 23.7–75.3%). Adhesions were found to be the predominant cause of obstruction. NOM did not appear to increase short-term complications. Most SBOs in patients without previous abdominal surgery are adhesive in nature and many patients can be discharged from hospital without surgery. While the short-term outcomes of NOM are acceptable, future studies are needed to address the long-term outcomes and safety of NOM as a treatment strategy for SBO in patients without previous abdominal surgery.

Background Rectal cancer patients undergoing preoperative radiotherapy experience a significant symptom burden. However, it is unknown whether symptoms during radiotherapy may portend adverse postoperative outcomes and healthcare utilization. Methods A retrospective cohort study was performed of rectal cancer patients undergoing neoadjuvant radiotherapy and proctectomy in Ontario from 2007 to 2014. The primary outcome was a complicated postoperative course–a dichotomous variable created as a composite of postoperative mortality, major morbidity, or hospital readmission. Patient-reported Edmonton Symptom Assessment System (ESAS) scores, collected routinely at outpatient provincial cancer center visits, were linked to administrative healthcare databases. The receiver-operating characteristic analysis was used to compare ESAS scoring approaches and to stratify patients into low versus high symptom score groups. Multivariable regression models were constructed to evaluate associations between preoperative symptom scores and postoperative outcomes. Results 1455 rectal cancer patients underwent sequential radiotherapy and proctectomy during the study period and recorded symptom assessments. Patients with high preoperative symptom scores were significantly more likely to experience a complicated postoperative course (OR 1.55, 95% CI 1.23-1.95). High preoperative ESAS scores were also associated with the secondary outcomes of emergency department visits (OR 1.34, 95% CI 1.08-1.66) and longer length of stay (IRR 1.23, 95% CI 1.04-1.45). Conclusions Rectal cancer patients reporting elevated symptom scores during neoadjuvant radiotherapy have increased odds of experiencing a complicated postoperative course. Preoperative patient-reported outcome screening may be a useful tool to identify at-risk patients and to efficiently direct perioperative supportive care.

Red blood cell transfusions (RBCT) remain a concern for patients undergoing hepatectomy. The effect of tranexamic acid (TXA), an anti-fibrinolytic, on receipt of RBCT in colorectal liver metastases (CRLM) resection was examined.Hepatectomies for CRLM over 2009-2014 were included. Primary outcome was 30-day receipt of RBCT. Secondary outcomes were 30-day major morbidity (Clavien-Dindo III-V) and 90-day mortality. Multivariable modelling examined the adjusted association between TXA and outcomes.Of 433 included patients, 146 (34%) received TXA. TXA patients were more likely to have inflow occlusion (41.8% vs. 23.1%; p 0.01) and major hepatectomies (56.1% vs. 45.6%; p = 0.0193). TXA was independently associated with lower risk of RBCT (Relative risk (RR) 0.59; 95% confidence interval (95%CI): 0.42-0.85), but not with 30-day major morbidity (adjusted RR 1.02; 95%CI: 0.64-1.60) and 90-day mortality (univariable RR 0.99; 95%CI: 0.95-1.03).Intraoperative TXA was associated with a 41% reduction in risk of 30 -day receipt of RBCT after hepatectomy for CRLM. This finding is important to potentially improve healthcare resource allocation and patient outcomes. Pending further evidence, intraoperative TXA may be an effective method of reducing RBCT in hepatectomy for CRLM.

BACKGROUND: Addressing nonmedical reasons for delays in hospital discharge is important for improving the flow of patients through acute care hospital beds. Because this problem is understudied among adult surgical patients, we examined the incidence of and identified factors associated with delayed hospital discharge after major elective and emergency surgical procedures in acute care institutions. METHODS: Using health administrative data, we retrospectively compared adults with and without delayed discharge after 18 major elective and emergency surgical procedures between 2006 and 2016 in Ontario hospitals. We identified delayed discharge using the alternate level of care code, applied to patients who are medically fit for discharge but remain in an acute care hospital bed. We used hierarchical logistic regression modelling to determine factors associated with delayed discharge. RESULTS: Our cohort included 595 782 patients who underwent elective procedures and 180 478 who underwent emergency procedures. Delayed discharge accounted for 635 607 hospital days, of which 81.7% were related to admissions for emergency surgery. Delayed discharge affected 3.1% of patients who underwent elective surgery and 19.6% of those who underwent emergency procedures. Days attributed to delayed discharge formed about one-third of patients’ total hospital stay for both surgical groups. The rate of delayed discharge across surgical specialties showed high variability (from 0.9% for lung resection or nephrectomy to 9.3% for peripheral arterial disease procedures in the elective surgery group, and from 3.8% for cardiac procedures to 33.8% for peripheral arterial disease procedures in the emergency surgery group). Risk factors for delayed discharge were older age, female sex, chronic disease burden and increasing hospital size. INTERPRETATION: Delayed discharge for nonmedical reasons was more common after emergency surgery than after elective surgery, and rates varied across surgery type. Optimizing early discharge planning, evaluating the variation in delayed discharge at the hospital level and improving local access to community care services could be next steps to addressing this problem.

Background Adhesive small bowel obstruction (aSBO) is a potentially recurrent disease. Although non‐operative management is often successful, it is associated with greater risk of recurrence than operative intervention, and may have greater downstream morbidity and costs. This study aimed to compare the current standard of care, trial of non‐operative management (TNOM), and early operative management (EOM) for aSBO. Methods Patients admitted to hospital between 2005 and 2014 in Ontario, Canada, with their first episode of aSBO were identified and propensity‐matched on their likelihood to receive EOM for a cost–utility analysis using population‐based administrative data. Patients were followed for 5 years to determine survival, recurrences, adverse events and inpatient costs to the healthcare system. Utility scores were attributed to aSBO‐related events. Cost–utility was presented as the incremental cost‐effectiveness ratio (ICER), expressed as Canadian dollars per quality‐adjusted life‐year (QALY). Results Some 25 150 patients were admitted for aSBO and 3174 (12·6 per cent) were managed by EOM. Patients managed by TNOM were more likely to experience recurrence of aSBO (20·9 per cent versus 13·2 per cent for EOM; P, This population‐based cost–utility analysis compared early operative management (EOM) for adhesive small bowel obstruction (SBO) to the current standard of care of a trial of non‐operative management. Although EOM was more costly, it was associated with a significantly lower risk of recurrence and reduced exposure to the morbidity and costs associated with multiple admissions for adhesive SBO. With longer follow‐up, EOM becomes increasingly cost‐effective, and crosses published willingness‐to‐pay thresholds within 5 years of the first admission. Early operative management in small bowel occlusion

Background Surgical site infections cause substantial morbidity and mortality. Negative pressure wound therapy may reduce the risk of surgical site infections, but current evidence is unclear. The objective of this study was to examine whether negative pressure wound therapy reduces the risk of surgical site infections and other wound complications when compared with conventional dressings in all patients with primarily closed surgical wounds. Methods A comprehensive systematic review of randomized controlled trials was conducted. Trials that compared a negative pressure wound therapy system to any non-negative pressure wound therapy dressing in surgical wound(s) intended to heal by primary intention were eligible. Surgical site infection was the primary outcome, and secondary outcomes included wound dehiscence, pain, seroma, healing time, length of stay, device-related complications, cost-effectiveness, and quality of life. Selection, extraction, and risk of bias steps were done in duplicate, and data were synthesized using random effects meta-analyses. A priori sensitivity and subgroup analyses of the primary outcome were completed. The Grading of Recommendations, Assessment, Development, and Evaluations framework was used to appraise the quality of the evidence. Results Forty-four randomized controlled trials with N = 5,693 patients were included. Patients treated with negative pressure wound therapy experienced nearly a 40% reduction in the risk of surgical site infections relative to those with conventional dressings, which was statistically significant: pooled risk ratio 0.61, 95% confidence interval 0.49–0.74, I2 = 26%. The effect remained consistent across surgical specialties and brands of negative pressure wound therapy devices. A statistically significant reduction in wound dehiscence and seroma incidence was also observed. Conclusion There is moderate certainty that negative pressure wound therapy applied to closed surgical incisions reduces the risk of surgical site infections across all surgical procedures.

Patients with metastatic gastric cancer have poor survival outcomes and may experience high symptom burden. We evaluated symptom trajectory and risk factors for increased symptom severity among metastatic gastric cancer patients during the last 6 months of life. We conducted a retrospective cohort study among patients ≥ 18 years diagnosed with metastatic gastric cancer from January 2007 to December 2014 in the province of Ontario, Canada. We included patients who died during the study period and who reported at least one Edmonton Symptom Assessment System (ESAS) score during the last 6 months of life. We described the proportion of patients who reported moderate-to-severe symptom scores (≥ 4) by month. Multivariable logistic regression models were created to identify risk factors for moderate-to-severe symptom scores. Seven hundred eighty-eight eligible patients with 3286 unique symptom scores completed during their last 6 months of life were identified. The highest prevalence of moderate-to-severe scores was observed for tiredness and lack of appetite, while nausea and depression had the lowest prevalence of elevated scores. The prevalence of moderate-to-severe was consistently high for all symptoms, particularly approaching end-of-life. Timing of ESAS scores, receipt of cancer-directed therapy, urban residence, and female sex were associated with increased odds of reporting moderate-to-severe symptom scores. Patients with metastatic gastric cancer experience significant symptom burden at the end-of-life. Routine screening with patient-reported outcome tools may assist in shared decision-making and effective palliative care by ensuring patients’ health status and supportive care needs are identified promptly at the time of clinical encounters.

Objective Describe clinical outcomes (eg, postoperative complications, survival) after robotic surgery compared to open or laparoscopic surgery. Background Robotic surgery utilization has increased over the years across a wide range of surgical procedures. However, evidence supporting improved clinical outcomes after robotic surgery is limited. Methods We systematically searched MEDLINE, EMBASE, and the Cochrane Central Register of systematic reviews from inception to January 2019 for systematic reviews describing postoperative outcomes after robotic surgery. We qualitatively described patient outcomes of commonly performed robotic procedures: radical prostatectomy, hysterectomy, lobectomy, thymectomy, rectal resection, partial nephrectomy, distal gastrectomy, Roux-en-Y gastric bypass, hepatectomy, distal pancreatectomy, and cholecystectomy. Results One hundred fifty-four systematic reviews included 336 studies and 18 randomized controlled trials reporting on patient outcomes after robotic compared to laparoscopic or open procedures. Data from the randomized controlled trials demonstrate that robotic-assisted radical prostatectomy offered fewer biochemical recurrence and improvement in quality of recovery and pain scores only up to 6 weeks postoperatively compared to open radical prostatectomy. When compared to laparoscopic prostatectomy, robotic surgery offered improved urinary and sexual functions. Robotic surgery for endometrial cancer had fewer conversion to open compared to laparoscopic. Otherwise, robotic surgery outcomes were similar to conventional surgical approaches for other procedures except for radical hysterectomy where minimally invasive approaches may result in patient harm compared to open approach. Conclusion Robotic surgery has been widely incorporated into practise despite limited supporting evidence. More rigorous research focused on patient-important benefits is needed before further expansion of robotic surgery.

Tranexamic acid reduces blood loss and transfusion requirements with no significant thrombotic adverse effects. Postoperative seizures have been seen in cardiac surgical patients in association with patient (advanced age, underlying neurologic disease, chronic kidney disease); surgical (open cardiac procedures, long bypass times); and drug (high tranexamic acid dose) risk factors. Tranexamic acid dosing regimens should be decreased in patients with chronic kidney dysfunction secondary to reduced clearance and drug accumulation. Optimal dosing for cardiac surgical patients has been recommended. Additional research is required to determine dosing regimens in major noncardiac surgery and plasma concentration levels associated with inducing seizures.

Background Robotic surgery was integrated into some healthcare systems despite there being few well designed, real-world studies on safety or benefit. This study compared the safety of robotic with laparoscopic, thoracoscopic, and open approaches in common robotic procedures. Methods This was a population-based, retrospective study of all adults who underwent prostatectomy, hysterectomy, pulmonary lobectomy, or partial nephrectomy in Ontario, Canada, between 2008 and 2018. The primary outcome was 90-day total adverse events using propensity score overlap weights, and secondary outcomes were minor or major morbidity/adverse events. Results Data on 24 741 prostatectomy, 75 473 hysterectomy, 18 252 pulmonary lobectomy, and 6608 partial nephrectomy operations were included. Relative risks for total adverse events in robotic compared with open surgery were 0.80 (95 per cent c.i. 0.74 to 0.87) for radical prostatectomy, 0.44 (0.37 to 0.52) for hysterectomy, 0.53 (0.44 to 0.65) for pulmonary lobectomy, and 0.72 (0.54 to 0.97) for partial nephrectomy. Relative risks for total adverse events in robotic surgery compared with a laparoscopic/thoracoscopic approach were 0.94 (0.77 to 1.15), 1.00 (0.82 to 1.23), 1.01 (0.84 to 1.21), and 1.23 (0.82 to 1.84) respectively. Conclusion The robotic approach is associated with fewer adverse events than an open approach but similar to a laparoscopic/thoracoscopic approach. The benefit of the robotic approach is related to the minimally-invasive approach rather than the platform itself.

OBJECTIVE To systematically review and meta-analyze whether the application of cryotherapy on closed incisions reduces postoperative pain and opioid consumption. BACKGROUND Reduction of acute pain and opioid use is important in the postoperative phase of patient care. "Cryotherapy" refers to the use of low temperatures for therapeutic purposes. METHODS MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Online registries of clinical trial were search until October 2019. RCT that examined postoperative application of cryotherapy over surgical incisions in adults compared to no cryotherapy were eligible. Selection, extraction, and risk of bias appraisal were completed in duplicate. Data were synthesized using random effects meta-analyses. The outcomes of interest were postoperative pain, opioid use, hospital length of stay (LOS) and surgical site infection (SSI). RESULTS Fifty-one RCTs (N = 3425 patients) were included. With moderate certainty evidence, patients treated with cryotherapy experienced a reduction in pain on postoperative day 1 (standardized mean differences -0.50, 95% CI -0.71 to -0.29, I2= 74%) and day 2 (standardized mean differences -0.63, 95% CI -0.91 to -0.35, I2= 83%) relative to without cryotherapy application. With moderate certainty of evidence, cryotherapy reduces opioid consumption in morphine milliequivalents and morphine milliequivalents/kg, (mean differences -7.43, 95% CI -12.42, -2.44, I2= 96%) and (mean differences -0.89, 95% CI -1.45, -0.33, I2= 99%), respectively. With low certainty evidence, cryotherapy does not affect hospital LOS or rate of SSI. CONCLUSION Cryotherapy is a pragmatic, noncostly intervention that reduces postoperative pain and opioid consumption with no effect on SSI rate or hospital LOS.

Background Venous thromboembolism (VTE) and bleeding are serious and potentially fatal complications of surgical procedures. Pharmacological thromboprophylaxis decreases the risk of VTE but increases the risk of major post-operative bleeding. The decision to use pharmacologic prophylaxis therefore represents a trade-off that critically depends on the incidence of VTE and bleeding in the absence of prophylaxis. These baseline risks vary widely between procedures, but their magnitude is uncertain. Systematic reviews addressing baseline risks are scarce, needed, and require innovations in methodology. Indeed, systematic summaries of these baseline risk estimates exist neither in general nor gynecologic surgery. We will fill this knowledge gap by performing a series of systematic reviews and meta-analyses of the procedure-specific and patient risk factor stratified risk estimates in general and gynecologic surgeries. Methods We will perform comprehensive literature searches for observational studies in general and gynecologic surgery reporting symptomatic VTE or bleeding estimates. Pairs of methodologically trained reviewers will independently assess the studies for eligibility, evaluate the risk of bias by using an instrument developed for this review, and extract data. We will perform meta-analyses and modeling studies to adjust the reported risk estimates for the use of thromboprophylaxis and length of follow up. We will derive the estimates of risk from the median estimates of studies rated at the lowest risk of bias. The primary outcomes are the risk estimates of symptomatic VTE and major bleeding at 4 weeks post-operatively for each procedure stratified by patient risk factors. We will apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rate evidence certainty. Discussion This series of systematic reviews, modeling studies, and meta-analyses will inform clinicians and patients regarding the trade-off between VTE prevention and bleeding in general and gynecologic surgeries. Our work advances the standards in systematic reviews of surgical complications, including assessment of risk of bias, criteria for arriving at the best estimates of risk (including modeling of the timing of events and dealing with suboptimal data reporting), dealing with subgroups at higher and lower risk of bias, and use of the GRADE approach. Systematic review registration PROSPERO CRD42021234119

OBJECTIVE Determine the association between the rate of early operative management for adhesive small bowel obstruction (aSBO) at the hospital-level and the incidence of morbidity and mortality. BACKGROUND Mounting evidence of the benefits of early operation in patients with aSBO has translated to both an increase in the proportion of patients treated operatively, and the proportion of patients who undergo early operative management. However, variation in practice remains. METHODS We identified a population-based cohort of patients (18-80 years) who were admitted with their first episode of aSBO (2005-2014). The exposures of interest were hospital characteristics and the primary outcome measure was 30-day mortality. Hierarchical logistic regression models were used to evaluate hospital-level variation on 30-day mortality, serious complications, and bowel resection. RESULTS A total of 27,026 patients were admitted to 122 hospitals, 23% (n = 6090) were managed operatively, 7% (n = 1845) had a serious complication, and 30-day mortality was 4.2% (n = 1146). The proportion of patients managed with early operation ranged from 0% to 33% [median 10% (interquartile range: 5%-14%)]. There was a 17% lower likelihood of 30-day mortality for every 10% increase in proportion of patients managed with an early operation at the hospital-level (odds ratio: 0.83, 95% confidence interval: 0.70-0.99). CONCLUSIONS Hospitals with a higher proportion of aSBO patients treated with an early operation had a lower likelihood of serious complications, bowel resection, and death, independent of hospital type and volume of aSBO admissions. Early operative intervention rates likely are a proxy for additional structures and processes of care focused on aSBO patients that may facilitate patient selection.

Compassion fatigue (CF) is the profound sense of emotional exhaustion that care providers can experience as the result of helping others in distress. CF can contribute to burnout (BO), depression, and stress-related illness. While surgeons and surgical trainees may be at high risk for developing CF, it has not been adequately characterized or explored in this population. The objective of this study was to examine the prevalence and impact of CF in surgical trainees with a view to inform a management strategy.A mixed method study was conducted using survey and interview methods. An email survey including the Professional Quality of Life Scale Version 5, an instrument to assess CF, was sent to all trainees in the Department of Surgery at the University of Toronto. Survey data were analyzed descriptively and using one-sample t tests. Semistructured interviews were conducted with volunteered trainees. Data collection and analysis occurred iteratively and inductively using the constant comparison method.One hundred fifteen trainees completed the survey representing a 47% response rate. Ninety-nine respondents (40.7%) completed the Professional Quality of Life Scale tool. The mean score on the compassion satisfaction subscale was 36.9 (SD 6.7), on the BO subscale was 26.2 (SD 5.6), and on the secondary traumatic stress (STS) subscale was 21.2 (SD 6.3). The mean on the compassion satisfaction subscale was not statistically different from the population mean (p = 0.22). The means for the BO and STS scales were statistically higher in our study sample compared to the normative data (p0.0001 for each). Thematic qualitative findings indicated trainees experienced CF symptoms. Participants described systemic barriers to mitigating CF including workload and a cultural expectation to be unemotional at work.Surgical trainees report high levels of BO and STS and currently use informal coping strategies outside of their academic and hospital environments. Trainees are likely to welcome and benefit from an organized response to support their emotional health when facing difficult patient encounters.

PurposeLate gadolinium hyperintensity (LGH) is sometimes seen in colorectal liver metastasis (CRLM) and represents a significant diagnostic pitfall due to overlap with LGH in benign hemangiomas; therefore, the objective of this study was to determine the prevalence of LGH and the ability of LGH to differentiate between CRLM and benign lesions with intravascular (gadofosveset) vs extracellular contrast agents (gadobutrol).MethodsPatients with known colorectal cancer and suspected liver lesions were prospectively recruited into this institutional review board–approved, single institution study and received magnetic resonance imaging of the liver with gadofosveset and gadobutrol. The prevalence of LGH for CRLMs and solid benign lesions was determined. Receiver operating characteristics curves were determined for the presence of LGH as a predictor of benignity. The utility of LGH to differentiate between CRLM and solid benign lesions using gadofosveset vs gadobutrol was compared using the generalized estimating equation.ResultsTwenty-five patients with 131 solid focal liver lesions were recruited. The prevalence of LGH of CRLMs was 11.2% (95% confidence interval [CI]: 0.5%–21.8%) with gadofosveset vs 63.7% (95% CI: 45.7%–81.7%) with gadobutrol. The area under the receiver operating characteristic curve for the presence of LGH as a predictor of benignity was 0.86 using gadofosveset vs 0.75 using gadobutrol. Both LGH ( P = .003) and the interaction of contrast agent and LGH ( P = .003) statistically significantly differentiated CRLM from benign lesions.ConclusionLGH is more common with extracellular than with intravascular contrast agents and is statistically significantly associated with benign lesions rather than metastases.

Background Adhesive small-bowel obstruction (aSBO) is among the most common reasons for admission to a surgical service. While operative intervention for aSBO is associated with a lower risk of recurrence, current guidelines continue to advocate a trial of nonoperative management. The impact of the increased risk for recurrence on long-term survival is unknown. We sought to explore the potential for improved survival with operative management through the prevention of admissions for recurrence of aSBO and the associated risks. Methods This is a population-based retrospective cohort study using administrative data. We identified patients admitted to hospital for their first episode of aSBO from 2005 to 2014 and created a propensity-matched cohort to compare survival of patients managed operatively with those managed nonoperatively. To test whether survival differences were mediated by recurrence prevention, a competing risk regression was used to model the subdistribution hazard of death when accounting for the risk of recurrence. An instrumental variable approach was used as a secondary analysis to compare survival while accounting for unmeasured confounding. Results There were 27,904 patients admitted for their first episode of aSBO between 2005 and 2014. The mean age was 61.2 years (std dev, 13.6), and 51% were female. Operative management was associated with a significantly lower risk of death (hazard ratio, 0.80; 95% confidence interval, 0.75-0.86), which was robust to instrumental variable analyses, and a lower risk of recurrence (hazard ratio, 0.59; 95% confidence interval, 0.54-0.65). When adjusting for the risk of recurrence, operative intervention was not associated with improved survival, suggesting that the survival benefit is mediated through prevention of recurrences of aSBO. Conclusion In patients admitted for their first episode of aSBO, operative intervention is associated with a significant long-term survival benefit. This survival benefit appears to be mediated through the prevention of recurrences of aSBO. Study type Retrospective cohort study. Level of evidence Therapeutic study, Level II.

To estimate long-term mortality following major burn injury compared with matched controls.The effect of sustaining a major burn injury on long-term life expectancy is poorly understood.Using health administrative data, all adults who survived to discharge after major burn injury between 2003 and 2013 were matched to between 1 and 5 uninjured controls on age, sex, and the extent of both physical and psychological comorbidity. To account for socioeconomic factors such as residential instability and material deprivation, we also matched on marginalization index. The primary outcome was 5-year all-cause mortality, and all patients were followed until death or March 31, 2014. Cumulative mortality estimates were estimated using the Kaplan-Meier method. Cox proportional hazards modeling was used to estimate the association of burn injury with mortality.In total, 1965 burn survivors of mean age 44 (standard deviation 17) years with median total body surface area burn of 15% [interquartile range (IQR) 5-15] were matched to 8671 controls and followed for a median 5 (IQR 2.5-8) years. Five-year mortality was significantly greater among burn survivors (11 vs 4%, P0.001). The hazard ratio was greatest during the first year (4.15, 95% CI 3.17-5.42), and declined each year thereafter, reaching 1.65 (95% CI 1.02-2.67) in the fifth year after discharge. Burn survivors had increased mortality related to trauma (mortality rate ratio, MRR 9.8, 95% CI 5-19) and mental illness (MRR 9.1, 95% CI 4-23).Burn survivors have a significantly higher rate of long-term mortality than matched controls, particularly related to trauma and mental illness. Burn follow-up should be focused on injury prevention, mental healthcare, and detection and treatment of new disease.

Background Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. Methods An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. Results The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. Conclusions PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.

To determine if late gadolinium MRI enhancement of colorectal liver metastases (CRCLM) is associated with overall survival among nonsurgical patients. This retrospective study was approved by the institutional research ethics board. Late gadolinium enhancement was measured using target tumour enhancement (TTE) in all nonsurgical patients with CRCLM who received a 10-min delayed phase gadobutrol-enhanced liver MRI between March 1, 2006, and August 31, 2014. A total of 122 patients met inclusion/exclusion criteria. Patients were dichotomized into strong and weak TTE. Kaplan-Meier and Cox regression statistics were used to determine whether TTE was associated with overall survival. Noncontributory potential confounding variables (age, sex, number and size of metastases, carcinoembryonic (CEA) level, and presence of extrahepatic disease) were excluded from the final Cox regression model using the backward Wald elimination. Subgroup Kaplan-Meier survival analyses were performed on patients who were chemotherapy-naive and chemotherapy-treated at the time of MRI. Strong TTE had increased survival compared with those with weak TTE on Kaplan-Meier analysis (2-year survival: 69.8% vs. 43.5%, p = 0.002). Among 96 patients where data was available for multivariable analysis, weak TTE was associated with death (adjusted hazard ratio 0.25, 95% CI 0.11–0.59, p = 0.002), after adjusting for CEA level. Other potential confounders were noncontributory. Subgroup analyses demonstrated that strong TTE had increased survival compared with those with weak TTE in both the chemotherapy-naive (p = 0.047) and chemotherapy-treated (p = 0.008) groups. Strong late gadolinium MRI enhancement of CRCLM is associated with overall survival among nonsurgical patients. • MRI enhancement of colorectal liver metastases is associated with overall survival in nonsurgical patients. • MRI enhancement of colorectal liver metastases is associated with overall survival in both chemotherapy-naive and chemotherapy-treated subgroups.

In this work, we assess the reproducibility and prognostic value of CT-derived radiomic features for resectable pancreatic ductal adenocarcinoma (PDAC). Two radiologists contoured tumour regions on pre-operative CT of two cohorts from two institutions undergoing curative-intent surgical resection for PDAC. The first (n = 30) and second cohorts (n = 68) were used for training and validation of proposed prognostic model for overall survival (OS), respectively. Radiomic features were extracted using PyRadiomics library and those with weak inter-reader reproducibility were excluded. Through Cox regression models, significant features were identified in the training cohort and retested in the validation cohort. Significant features were then fused via Cox regression to build a single radiomic signature in the training cohort, which was validated across readers in the validation cohort. Two radiomic features derived from Sum Entropy and Cluster Tendency features were both robust to inter-reader reproducibility and prognostic of OS across cohorts and readers. The radiomic signature showed prognostic value for OS in the validation cohort with hazard ratios of 1.56 (P = 0.005) and 1.35 (P = 0.022), for the first and second reader, respectively. CT-based radiomic features were shown to be prognostic in patients with resectable PDAC. These features may help stratify patients for neoadjuvant or alternative therapies.

Previous studies have demonstrated that target tumor enhancement (TTE) of colorectal cancer liver metastases (CRCLM) on 10-minute delayed phase gadobutrol-enhanced MRI is associated with overall survival post-hepatectomy. The purpose of this study was to determine whether TTE of CRCLM on preoperative gadobutrol-enhanced MRI measured at 5-minute delayed phase is also associated with overall survival. We performed a single-institution, REB-approved, retrospective study of 121 patients with CRCLM who had received a clinical gadobutrol-enhanced MRI after treatment with chemotherapy and prior to liver surgery between January 1, 2006 and December 31, 2012. The TTE of the colorectal liver metastases (CRLM) on 5-minute delayed phase was determined. Kaplan-Meier and Cox-regression survival analyses were used in order to determine the association between TTE on 5-minute delayed phase and overall survival, after adjusting for known prognostic variables. TTE of chemotherapy-treated CRLM on gadobutrol-enhanced MRI at 5-minute post-contrast injection is associated with overall survival post-hepatectomy. On Kaplan-Meier survival analysis, there was a significant difference in overall survival between strong and weak TTE groups (log-rank P=0.009) with 74.4% survival at 36 months in the strong TTE group compared to only 44.6% in the weak TTE group. On Cox-regression analysis, the adjusted hazard ratio of death for patients with low TTE was 0.40 (95% CI: 0.18-0.90, P=0.026), after adjusting for known prognostic variables. This study provides preliminary evidence that tumor enhancement of CRLM at 5 minutes post-contrast injection on gadobutrol-enhanced MRI may provide preoperative prognostic information. This may be helpful for risk stratification of patients for surgery.

Robotic surgery is used in several surgical procedures with limited evidence of clinical benefit. In some jurisdictions, the demand for robotic surgery may have been fueled by public perception of this novel technology. Therefore, we sought to investigate the public's perception of robotic surgery.We conducted a cross-sectional survey using a series of vignette-associated questions designed to examine the public's perception of robotic surgery. Eligible participants were recruited through Amazon Mechanical Turk's system and randomized to one of two pairs of vignettes: laparoscopic surgery compared to (1) robotic surgery, or (2) "novel surgical technology" (without using the term "robotic"). Outcomes of interest were anticipated postoperative outcomes using the surgical fear questionnaire, procedure preference, perception of error, trust, and competency of the surgeon.The survey included 362 respondents; 64.1% were male with median age of 53 years. There were no differences in the distribution of responses of the questionnaire based on use of the term "robotic" or "novel surgical technology"; therefore, the two cohorts were combined to examine perception of robotic compared to laparoscopic surgery. More respondents feared outcomes of robotic surgery than laparoscopic surgery (78.2% vs 14.9%, p 0.001). Participants preferred laparoscopic to robotic surgery (64.4% vs 35.6%, p 0.001).The public fears recovery after robotic surgery and prefers laparoscopic surgery. The propagation of robotic surgery is unlikely based on public demand and may be more related to institutional or surgeon perceptions. Surgeons who provide robotic surgery should ensure their patients are comfortable with and understand this technology.

While the contemporary management of adhesive small bowel obstruction (SBO) often includes a trial of non-operative management (NOM), surgical dogma dictates urgent operative exploration in patients without previous abdominal surgery. This dogma has been challenged by recent evidence suggesting most obstructions in this population are adhesive in nature. The objectives of this review were to evaluate the feasibility of NOM in patients with SBO and no history of previous abdominal surgery, to examine the etiologies of SBO in this population, and to explore the rate of adverse events seen following NOM. Embase, Medline, Cochrane, and Google Scholar were searched from inception to September 24, 2019. Articles reporting on NOM for SBO in patients without previous abdominal surgery and without clinical or radiographic features necessitating an emergent operation were included. Data were combined to obtain a pooled proportion of patients discharged without operation following a trial of NOM. 6 studies reporting on a total of 272 patients were included. The pooled proportion of patients discharged following NOM was 49.5% (95% CI 23.7-75.3%). Adhesions were found to be the predominant cause of obstruction. NOM did not appear to increase short-term complications. Most SBOs in patients without previous abdominal surgery are adhesive in nature and many patients can be discharged from hospital without surgery. While the short-term outcomes of NOM are acceptable, future studies are needed to address the long-term outcomes and safety of NOM as a treatment strategy for SBO in patients without previous abdominal surgery.

Administration of chemotherapy to patients with colorectal liver metastases may result in disappearing liver metastases (DLM). This poses a therapeutic dilemma due to the uncertainty of true complete (pathological) response.We aimed to examine the diagnostic performance of imaging modalities in detecting true complete response in patients with DLM after chemotherapy.We performed a systematic search for articles assessing the diagnostic performance of imaging modalities in evaluating DLM following chemotherapy. True complete response was defined as 1-year recurrence-free survival in non-resected patients or complete pathological response on histologic examination in resected patients. We calculated the negative predictive value (NPV) for detecting true complete response of each imaging modality using a random effects model.Thirteen studies comprising 332 patients with at least one DLM were included. The number of DLMs after chemotherapy was 955 with computed tomography (CT), 104 with positron emission tomography (PET), 50 with intraoperative ultrasound (IOUS), 585 with magnetic resonance imaging (MRI), and 175 with contrast-enhanced IOUS (CEIOUS). Substantial variation in study design, patient characteristics, and imaging features was observed. Pooled NPV was 0.79 (95% confidence interval [CI] 0.53-0.96), 0.73 (95% CI 0.58-0.85), 0.54 (95% CI 0.37-0.7), 0.47 (95% CI 0.34-0.61), and 0.22 (95% CI 0.11-0.39) for CEIOUS, MRI, IOUS, CT, and PET, respectively.After chemotherapy, MRI or CEIOUS are the most accurate imaging modalities for assessment of DLM and should be used routinely in this context. Given the high NPV of these two modalities, surgical resection of visible CRLM is warranted if technically possible, even if DLM remain.

Introduction Hepatic artery infusion pump (HAIP) chemotherapy is a specialized therapy for patients with unresectable colorectal liver metastases (uCRLM). Its effectiveness was demonstrated from a high volume center, with uncertainty regarding the feasibility and safety at other centers. Therefore, we sought to assess the safety and feasibility of HAIP for the management of uCRLM at other centers. Methods We conducted a multicenter retrospective cohort study of patients with uCRLM treated with HAIP from January 2003 to December 2017 at six North American centers initiating the HAIP program. Outcomes included the safety and feasibility of HAIP chemotherapy. Results We identified 154 patients with HAIP insertion and the median age of 54 (48-61) years. The burden of disease was >10 intra-hepatic metastatic foci in 59 (38.3%) patients. Patients received at least one cycle of systemic chemotherapy before HAIP insertion. Major complications occurred in 7 (4.6%) patients during their hospitalization and 13 (8.4%) patients developed biliary sclerosis during follow-up. A total of 148 patients (96.1%) received at least one-dose of HAIP chemotherapy with a median of 5 (4-7) cycles. 78 patients (56.5%) had a complete or partial response and 12 (7.8%) received a curative liver resection. Conclusion HAIP programs can be safely and effectively initiated in previously inexperienced centers with good response.

Summary Background Although metformin is increasingly being used in women with type 2 diabetes during pregnancy, little data exist on the benefits and harms of metformin use on pregnancy outcomes in these women. We aimed to investigate the effects of the addition of metformin to a standard regimen of insulin on neonatal morbidity and mortality in pregnant women with type 2 diabetes. Methods In this prospective, multicentre, international, randomised, parallel, double-masked, placebo-controlled trial, women with type 2 diabetes during pregnancy were randomly assigned from 25 centres in Canada and four in Australia to receive either metformin 1000 mg twice daily or placebo, added to insulin. Randomisation was done via a web-based computerised randomisation service and stratified by centre and pre-pregnancy BMI ( ClinicalTrials.gov , NCT01353391 . Findings Between May 25, 2011, and Oct 11, 2018, we randomly assigned 502 women, 253 (50%) to metformin and 249 (50%) to placebo. Complete data were available for 233 (92%) participants in the metformin group and 240 (96%) in the placebo group for the primary outcome. We found no significant difference in the primary composite neonatal outcome between the two groups (40% vs 40%; p=0·86; relative risk [RR] 1·02 [0·83 to 1·26]). Compared with women in the placebo group, metformin-treated women achieved better glycaemic control (HbA1c at 34 weeks' gestation 41·0 mmol/mol [SD 8·5] vs 43·2 mmol/mol [–10]; 5·90% vs 6·10%; p=0·015; mean glucose 6·05 [0·93] vs 6·27 [0·90]; difference −0·2 [–0·4 to 0·0]), required less insulin (1·1 units per kg per day vs 1·5 units per kg per day; difference −0·4 [95% CI −0·5 to −0·2]; p Interpretation We found several maternal glycaemic and neonatal adiposity benefits in the metformin group. Along with reduced maternal weight gain and insulin dosage and improved glycaemic control, the lower adiposity and infant size measurements resulted in fewer large infants but a higher proportion of small-for-gestational-age infants. Understanding the implications of these effects on infants will be important to properly advise patients who are contemplating the use of metformin during pregnancy. Funding Canadian Institutes of Health Research, Lunenfeld-Tanenbaum Research Institute, University of Toronto.

As an analytic pipeline for quantitative imaging feature extraction and analysis, radiomics has grown rapidly in the past a few years. Recent studies in radiomics aim to investigate the relationship between tumors imaging features and clinical outcomes. Open source radiomics feature banks enable the extraction and analysis of thousands of predefined features. On the other hand, recent advances in deep learning have shown significant potential in the quantitative medical imaging field, raising the research question of whether predefined radiomics features have predictive information in addition to deep learning features. In this study, we propose a feature fusion method and investigate whether a combined feature bank of deep learning and predefined radiomics features can improve the prognostics performance. CT images from resectable Pancreatic Adenocarcinoma (PDAC) patients were used to compare the prognosis performance of common feature reduction and fusion methods and the proposed risk-score based feature fusion method for overall survival. It was shown that the proposed feature fusion method significantly improves the prognosis performance for overall survival in resectable PDAC cohorts, elevating the area under ROC curve by 51% compared to predefined radiomics features alone, by 16% compared to deep learning features alone, and by 32% compared to existing feature fusion and reduction methods for a combination of deep learning and predefined radiomics features.

Background Cox proportional hazard model (CPH) is commonly used in clinical research for survival analysis. In quantitative medical imaging (radiomics) studies, CPH plays an important role in feature reduction and modeling. However, the underlying linear assumption of CPH model limits the prognostic performance. In this work, using transfer learning, a convolutional neural network (CNN) based survival model was built and tested on preoperative CT images of resectable Pancreatic Ductal Adenocarcinoma (PDAC) patients. Results The proposed CNN-based survival model outperformed the traditional CPH-based radiomics approach in terms of concordance index and index of prediction accuracy, providing a better fit for patients’ survival patterns. Conclusions The proposed CNN-based survival model outperforms CPH-based radiomics pipeline in PDAC prognosis. This approach offers a better fit for survival patterns based on CT images and overcomes the limitations of conventional survival models.

Background The study aims were to model acute pain intensity and opioid consumption trajectories up to 72 hr after open hepatic resection, identify predictors of trajectory membership and examine the association between trajectory memberships and 6-month pain and psychological outcomes. This is a long-term analysis of a published randomized controlled trial on the impact of medial open transversus abdominis plane catheters on post-operative outcomes. Methods A total of 152 patients (89 males; mean age 63.0 [range: 54-72]) completed questionnaires on pain and related characteristics pre-operatively and 6 months post-operatively. Total opioid use was recorded several times over a 72-hr period while self-reported pain intensity scores were collected multiple times until hospital discharge. Analyses were carried out using growth mixture modelling, logistic regression and general linear models. Results Both pain intensity and opioid consumption showed that a four-trajectory model best fits the data. Patients in the lowest opioid consumption trajectory were more likely to be classified in the constant mild pain intensity trajectory. Age and baseline levels of anxiety significantly predicted opioid trajectory membership while baseline depressive symptoms significantly predicted pain intensity trajectory membership. Patients in the two highest opioid consumption trajectories reported significantly higher levels of pain catastrophizing at 6 months compared to patients in the other 3 trajectories (all p Conclusion High consumption of opioids after surgery is associated with higher levels of pain catastrophizing 6 months later. Identification of patients within these trajectories may lead to the development of early interventions targeted to high risk individuals. Significance Differences in initial levels of opioid consumption and rates of change in opioid consumption shortly after surgery can help predict long-term psychological responses to pain. Identifying key characteristics associated with initial opioid consumption can lead to the development of cost-effective early interventions targeted to high risk individuals.

The surgical care of patients with metastatic gastric cancer (GC) remains debated. Despite level 1 evidence showing lack of survival benefit, surgery may be used for symptoms prevention or palliation. This study examined short-term postoperative outcomes of non-curative gastrectomy performed for metastatic GC. A multi-institutional retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry, including gastrectomies for GC (2007–2015). The primary outcome was 30-day major morbidity. Multivariable analysis examined the association between metastatic status and outcomes adjusted for relevant demographic and clinical covariates. Of 5341 patients, 377 (7.1%) had metastases. Major morbidity was more common with metastases (29.4 vs. 19.6%; p

In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level. This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005&ndash, 2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd. Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412). Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.

Objective Conventional management of pain following open liver resection involves intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. The objective of this trial was to assess the efficacy of a regional technique called Medial Open Transversus Abdominis Plane (MOTAP) catheter analgesia compared with IV PCA. Methods This was a blinded, randomized, controlled parallel-arm trial conducted at 2 high-volume centers. Patients undergoing liver resection through a subcostal incision were enrolled. Using a standardized technique, 2 catheters were placed after resection: one in the plane between internal oblique and transversus abdominis and the other in the posterior rectus sheath. Patients were randomized to receive ropivacaine 0.2% (ROP) or saline (NS) through both catheters for 72 hours. All patients received IV PCA with hydromorphone as part of a multimodality analgesia program. Primary outcome was opioid use over the first 48 hours. Results One hundred fifty-three patients were included in the analysis (71 ROP, 82 NS). Patients receiving ROP used significantly less opioid than patients with NS at 48 hours (median 39.6 mg morphine-equivalent vs 49.2 mg, P = 0.033) and at 72 hours (median 50.0 vs 66.4 mg, P = 0.046). Pain scores at rest and with coughing were significantly lower at all time points in patients who received ROP (P = 0.002). Median length of hospital stay was 5 days in patients receiving ROP and 6 days in patients who received NS (P = 0.035). There was no difference between groups in complications [ROP 20 (28.2%) vs NS 26 (31.7%), P = 0.63]. Conclusion MOTAP catheter analgesia reduces opioid requirements, pain, and length of hospital stay compared with IV PCA following open liver resection with subcostal incisions.

In patients with adhesive small bowel obstruction (aSBO), the decision to operate as well as the timing and technique of surgery have significant impacts on clinical outcomes. Trends in the management of aSBO have not been described at the population level and guideline adherence is unknown. We sought to evaluate the secular trends in the management of aSBO in a large North American population. We used administrative data to identify patients admitted to hospital for their first episode of aSBO over 2005–2014. We evaluated temporal trends in admission for aSBO and in management practices using Cochran-Armitage tests. Multivariable logistic regressions were used to assess trends when controlling for potential confounders. Patients (40,800) were admitted with their first episode of aSBO. The mean age was 68.5 years and 55% of patients were female. The population-based rate of admission for aSBO decreased over the study period, from 39.1 to 38.1 per 100,000 persons per year. There was a significant increase in the proportion of patients who underwent surgery for aSBO (19 to 23%, p

Purpose Improvement in the quality of life of patients with cancer requires attention to symptom burden across the continuum of care, with the use of patient-reported outcomes key to achieving optimal care. Yet there have been few studies that have examined symptoms in the early postdiagnosis period during which suboptimal symptom control may be common. A comprehensive analysis of temporal trends and risk factors for symptom burden in newly diagnosed patients with cancer is essential to guide supportive care strategies. Methods A retrospective observational study was performed of patients who were diagnosed with cancer between January 2007 and December 2014 and who survived at least 1 year. Patient-reported Edmonton Symptom Assessment System scores, which are prospectively collected at outpatient visits, were linked to provincial administrative health care data. We described the proportion of patients who reported moderate-to-severe symptom scores by month during the first year after diagnosis according to disease site. Multivariable logistic regression models were constructed to identify risk factors for moderate-to-severe symptom scores. Results Of 120,745 patients, 729,861 symptom assessments were recorded within 12 months of diagnosis. For most symptoms, odds of elevated scores were highest in the first month, whereas nausea had increased odds of elevated scores up to 6 months after diagnosis. On multivariable analysis, cancer site, younger age, higher comorbidity, female sex, lower income, and urban residence were associated with significantly higher odds of elevated symptom burden. Conclusion A high prevalence of moderate-to-severe symptom scores was observed in cancers of all sites. Patients are at risk of experiencing multiple symptoms in the immediate postdiagnosis period, which underscores the need to address supportive care requirements early in the cancer journey. Patient subgroups who are at higher risk of experiencing moderate-to-severe symptoms should be targeted for tailored supportive care interventions.

Due to significant improvements in morbidity and mortality, surgery with curative intent is now the standard of care for patients with colorectal liver metastases who are surgical candidates. As a result, highly accurate preoperative per-lesion diagnosis is crucial. However, in some instances, this remains limited with standard techniques, including magnetic resonance imaging (MRI) with conventional contrast agents. Delayed retention of contrast of fibrotic liver metastases on MRI with extracellular contrast agents may mimic the late retention of contrast in hemangiomas and represent a diagnostic pitfall that limits diagnosis. Early preliminary work suggests that this imaging pitfall may not be seen on MRI with intravascular contrast agents (e.g., gadofosveset). This case report describes a surgical patient with colorectal liver metastases where gadofosveset-enhanced liver MRI was helpful in determining patient management.

Create practice guidelines for the appropriate use of red blood cell transfusions in hepatectomy.Hepatectomy is associated with a high prevalence of transfusions. A transfusion can be life-saving, but can be associated with important adverse effects. Given the prevalence, the potential for benefit and harm, and the difficulty in conducting clinical trials, transfusion in hepatectomy is well-suited for a study of appropriateness.Using the RAND/UCLA appropriateness method, an international, multidisciplinary expert panel in hepatobiliary surgery, anesthesia, transfusion medicine, and critical care rated a series of 468 perioperative scenarios for transfusion appropriateness. Scenarios were rated individually, and again during an inperson group moderated session. Median scores and level of agreement were calculated to classify each scenario as appropriate, inappropriate, or uncertain.Approximately, 47.4% of scenarios were rated as appropriate for transfusion, 28.2% were inappropriate, and 24.4% were uncertain. The key recommendations for intraoperative transfusion were (i) it is never inappropriate to transfuse for significant bleeding or ST segment changes; (ii) it is never inappropriate to transfuse for an intraoperative hemoglobin ≤75 g/L; and (iii) in the absence of significant bleeding or ST changes, transfusion for hemoglobin of ≥95 g/L is inappropriate, and transfusion for hemoglobin of ≥85 g/L requires strong justification. The key recommendations for postoperative transfusions were: (i) in a stable, asymptomatic patient, an appropriate transfusion trigger is 70 g/L (without coronary artery disease) or 80 g/L (with coronary artery disease) and (ii) it is appropriate to transfuse any patient for a hemoglobin of ≤75 g/L either immediately post-operative, or with a significant decrease from the previous day (15 g/L).Based on best available evidence and expert opinion, criteria for appropriate perioperative red blood cell transfusions in hepatectomy were determined.

Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry, we identified all adult patients undergoing elective hepatectomy over 2007–2012. Two exposure groups were created based on RBCT. Primary outcomes were 30-day major morbidity and mortality. Secondary outcomes included 30-day system-specific morbidity and length of stay (LOS). Relative risks (RR) with 95% confidence interval (95% CI) were computed using regression analyses. Sensitivity analyses were conducted to understand how missing data might have impacted the results. Results: A total of 12,180 patients were identified. Of those, 11,712 met inclusion criteria, 2,951 (25.2%) of whom received RBCT. Major morbidity occurred in 14.9% of patients and was strongly associated with RBCT (25.3% vs. 11.3%; P