The Standardization of Outpatient Procedure (STOP) Narcotics after anorectal surgery: a prospective non-inferiority study to reduce opioid use.

BACKGROUND: Prescription of opioid medication after ambulatory anorectal surgery may be excessive and lead to opioid misuse. The purpose of this study was to evaluate the efficacy of a multi-modality opioid-sparing approach to control postoperative pain and reduce opioid prescriptions after outpatient anorectal surgery. METHODS: A prospective non-inferiority pre- and post-intervention study was completed at three academic hospitals. Patients included were 18-75 years of age who had outpatient anorectal surgeries. The Standardization of Outpatient Procedure (STOP) Narcotics intervention was implemented, which is a multi-pronged analgesia bundle integrating patient education, health care provider education, and intra-/postoperative analgesia focused on multi-modal pain control strategies and opioid-reduced prescriptions. The primary outcome was patient-reported average pain in the first 7 postoperative days. Secondary outcomes included patient-reported quality of pain management, medication utilization, prescription refills and medication disposal. RESULTS: Ninety-three patients had outpatient anorectal surgery (42 pre-intervention and 51 post-intervention). No difference was seen in average postoperative pain in the pre- vs. post-intervention groups (2.8 vs. 2.6 on an 11-point scale, p = 0.33) or patient-reported quality of pain control (good/very good in 57% vs. 63%, p = 0.58). The median oral morphine equivalents (OME) prescribed was significantly less [112.5 (IQR 50-150) pre-intervention vs. 50 (IQR 50-50) post-intervention, p < 0.001]. In the post-intervention group, only 45% of patients filled their opioid prescription and median opioid use was 12.5 OME (2.5 pills). CONCLUSIONS: While pain control after anorectal surgery must consider the individual patient's needs, a standardized pain care bundle significantly decreased opioid prescribing without an increase in patient-reported postoperative pain.

Long-term results of pylorus-preserving pancreatoduodenectomy for chronic pancreatitis.

OBJECTIVE: To assess the long-term outcome of patients following pylorus-preserving pancreatoduodenectomy (PPPD) for chronic pancreatitis. DESIGN: Retrospective study with mean follow-up of 63 months (range, 1 month to 13.7 years). SETTING: Tertiary referral hospital. PATIENTS: Records of all patients who underwent PPPD for chronic pancreatitis at Lahey Clinic were reviewed. All patients who were alive were contacted by telephone. In cases where patients had died, information was gathered from family members and hospital records. RESULTS: Forty-five patients underwent PPPD for disabling chronic pancreatitis. The mean preoperative duration of pain was 50 months, with 32 patients (70%) requiring daily narcotics. In one patient resection of the portal vein was required. One patient died within 30 days of the operation. Forty-one patients (92%) had improvement of pain at 5 years. The mean pain score (on a scale of 0 to 10) was 9.2 preoperatively and 1.5, 0.8, 1.1, and 1.1 at 6 months, 1 year, 2 years, and 5 years, respectively. Thirty-three patients (74%) had a postoperative weight gain to an average of 92% of their pre-illness weight. New-onset diabetes occurred in six patients (14%) by 6 months and in 21 patients (46%) by 5 years. Hypoglycemia was the cause of death in one patient who underwent total pancreatectomy. Four patients died of causes unrelated to PPPD. Marginal ulcers occurred in five patients (10%). Nine patients required late operations. CONCLUSIONS: In selected patients, resection of the head of the pancreas achieves long-term pain improvement in over 90% of cases. The early development of diabetes mellitus is infrequent, but over longer follow-up periods it reaches prevalence rates similar to those described in patients who have not undergone resection. Weight gain in this group was superior to that previously reported for our patients who underwent "standard Whipple" operation for chronic pancreatitis.

Attitudes toward trauma care of surgeons practising in Ontario.

OBJECTIVE: To assess the attitudes of practising surgeons in the province of Ontario toward issues in trauma care management. DESIGN: A survey by questionnaire. SETTING: The study was carried out in a university-affiliated hospital. The survey respondents generally practised in a nonteaching setting; 48% were over the age of 50 years; 81% worked in an institution with 24-hour in-house physician coverage for the emergency department. SUBJECTS: All 2294 surgeons registered with the Ontario Medical Association were surveyed by completion and return of a questionnaire; 191 surgeons were registered in Ontario but were not practising in the province and were excluded from the survey. Questionnaires were completed by 575 surgeons, but 49 were no longer in active practice, so 526 responses form the basis of this analysis. RESULTS: The response rate to the questionnaire was 27%. One-third of the respondents wished to treat no trauma patients at all; 47% believed that trauma patients had a negative impact on their surgical practice; only 19% considered that trauma patients had a positive impact. Surgeons had negative attitudes toward trauma because of the night and weekend profile of trauma, its effect on elective surgical practice, the poor rate of reimbursement for time spent in trauma management, and the potential medicolegal liability of trauma cases. CONCLUSIONS: These results suggest that there are few surgeons in Ontario who are truly committed to providing care to the injured patient. Strategies to overcome the perceived negative aspects of trauma care must be addressed because a crisis in the availability of surgeons to provide this care seems inevitable.

Lost gallstones during laparoscopic cholecystectomy: are they really benign?

The long-term effect of stones spilled into the peritoneal cavity during laparoscopic cholecystectomy is unknown. The course of a 58-year-old man who had recurrent right subphrenic abscesses and a right empyema secondary to spilled gallstones during laparoscopic cholecystectomy is described. The authors outline techniques for minimizing the spillage of stones during laparoscopic cholecystectomy: the application of hemoclips, endoloops and sutures, and placement of the necrotic, friable gallbladder in an endoscopic bag immediately upon completion of the dissection, before extraction of the gallbladder. They conclude that spillage of stones during laparoscopic cholecystectomy may lead to serious infection and should be recorded in the operative notes so that stones may be suspected when a patient presents with abdominal infection after laparoscopic cholecystectomy.

Synergistic effects of tumour necrosis factor and morphine on gut barrier function.

OBJECTIVE: To study the effects of tumour necrosis factor (TNF) and morphine on intestinal permeability, intestinal transit and bacterial translocation in the rat. DESIGN: A randomized interventional controlled experiment. SETTING: University surgery and microbiology research laboratory. PARTICIPANTS: Forty-four rats in five groups as follows: control (n = 9); treated with morphine every 2 hours for 8 hours (n = 9); treated with TNF for 5 minutes (n = 10); treated with TNF plus morphine every 2 hours for 8 hours (n = 6); and treated with TNF plus morphine every 3 hours for 24 hours (n = 10). MAIN OUTCOME MEASURES: Intestinal permeability as measured by the uptake of chromium-51 ethylenediaminetetraacetate (51Cr-EDTA) over 8 hours, intestinal transit as measured by the amount of 51Cr-EDTA remaining in the gastrointestinal tract at the time of animal sacrifice, intestinal bacteria counts and translocation of bacteria as measured from bacterial counts of mesenteric lymph nodes, spleen and liver at the time of sacrifice. RESULTS: Morphine increased intestinal transit time and ileal bacteria counts (p < 0.05). TNF alone did not increase intestinal permeability or bacterial translocation. TNF plus morphine increased intestinal transit time, intestinal permeability, bacterial counts and bacterial translocation (p < 0.05). CONCLUSIONS: Morphine or increased intestinal transit time, or both, increases the concentration of intestinal bacteria. Morphine plus TNF increases intestinal bacteria counts, intestinal permeability and bacterial translocation. Morphine alone does not increase intestinal permeability or bacterial translocation.

Embryotoxicity in mice of phosphonacetyl-L-aspartic acid (PALA), a new antitumor agent. II. Studies on its mechanism and reversibility.

The embryolethal effects of phosphonacetyl-L-aspartic acid (PALA) are markedly gestational stage-specific in the Swiss albino mouse. Embryos are most sensitive to the lethal effects of PALA on days 7 and 8 of gestation, with embryonic LD50's of 9 and 8 mg/kg, respectively. In contrast, the embryonic LD50 on day 10 of gestation is 144 mg/kg. Following an IP dose of (acetyl-14C)-PALA to pregnant mice, approximately threefold higher levels of radioactivity were present in day 8 than in day 10 embryonic tissue, whereas the radioactive content of placentas from day 10 pregnant animals was significantly higher than in placentas from day 8 pregnant mice. Similarly, L-aspartate transcarbamylase (ATCase) activity was greater in maternal spleen, placentas, and embryos on day 8 than on day 10 of gestation, and PALA treatment produced a greater inhibition of ATCase in embryonic tissue on day 8 than on day 10; however, inhibition of placental ATCase activity was more pronounced on day 10 than on day 8. Neither single nor multiple doses of uridine (UR) given orally to pregnant mice on day 8 of gestation were effective in reducing day 8 PALA embryolethality. Carbamyl-L-aspartic acid, given in the drinking water of pregnant mice on days 7-9 of gestation, reduced the day 8 embryolethality of PALA from 100% to approximately 50%. In a similar experiment, the presence of UR in the drinking water of pregnant mice reduced PALA-induced embryolethality in day 10, but not day 8, embryos. These results indicate that the embryotoxic effects of PALA are the result of ATCase inhibition; furthermore, they suggest that the relative insensitivity of the day 10 embryo to the lethal effects of PALA may result either from a greater availability of UR to the day 10 (versus the day 8) embryo, or from an enhanced ability of the day 10 placenta to bind PALA and prevent its passage into the embryo.