Background/Purpose:Documentation of resuscitation preferences is crucial for patients undergoing surgery. Unfortunately, this remains an area for improvement at many institutions. We conducted a quality improvement initiative to enhance documentation percentages by integrating perioperative resuscitation checks into the surgical workflow. Specifically, we aimed to increase the percentage of general surgery patients with documented resuscitation statuses from 82% to 90% within a 1-year period.Methods:Three key change ideas were developed. First, surgical consent forms were modified to include the patient's resuscitation status. Second, the resuscitation status was added to the routinely used perioperative surgical checklist. Finally, patient resources on resuscitation processes and options were updated with support from patient partners. An audit survey was distributed mid-way through the interventions to evaluate process measures.Results:The initiatives were successful in reaching our study aim of 90% documentation rate for all general surgery patients. The audit revealed a high uptake of the new consent forms, moderate use of the surgical checklist, and only a few patients for whom additional resuscitation details were added to their clinical note.Conclusions:We successfully increased the documentation percentage of resuscitation statuses within our large tertiary care center by incorporating checks into routine forms to prompt the conversation with patients early.

We present a fascinating case of a 57-year-old male with a novel mutation in MLH1 (MLH1:c.1288G > T, p.(Glu430*)), who presented with two synchronous colonic tumours, initially deemed unresectable, and experienced a complete pathological response on neoadjuvant pembrolizumab. Extensive genetic testing revealed post-zygotic mosaicism from the novel mutation.

Background: Patients with inflammatory bowel disease (IBD) post-liver transplant (LT) may have bowel inflammation requiring biologic therapy. We aimed to evaluate the safety of combination biologic and antirejection therapy in IBD patients after LT from a tertiary center case series and an updated literature review. Methods: Inflammatory bowel disease patients undergoing LT between 1985 and 2018 and requiring combination biologic and antirejection therapy post-LT were identified from the London Health Sciences Transplant Registry (Ontario, Canada). Safety outcomes were extracted by medical chart review. For an updated literature review, EMBASE, Medline, and CENTRAL were searched to identify studies evaluating the safety of combination biologic and antirejection therapy in IBD patients. Results: In the case series, 19 patients were identified. Most underwent LT for primary sclerosing cholangitis (PSC; 14/19, 74%) treated with anti-integrins (8/19, 42%) or tumor necrosis factor alpha (TNF) antagonists (6/19, 32%). Infections occurred in 11/19 (58%) patients, most commonly Clostridium difficile (4/19, 21%). Two patients required colectomy, and 1 patient required re-transplantation. In the literature review, 13 case series and 8 case reports reporting outcomes for 122 IBD patients treated with biologic and antirejection therapy post-LT were included. PSC was the indication for LT in 97/122 (80%) patients, and 91/122 (75%) patients were treated with TNF antagonists. Infections occurred in 32/122 (26%) patients, primarily Clostridium difficile (7/122, 6%). Conclusions: Inflammatory bowel disease patients receiving combination biologic and antirejection therapy post-LT appeared to be at increased risk of Clostridium difficile. Compared with the general liver transplant population in the published literature, there was no increased risk of serious infection.

BACKGROUND:Intensive surveillance strategies are currently recommended for patients after curative treatment of colon cancer, with the aim of secondary prevention of recurrence. Yet, intensive surveillance has not yielded improvements in overall patient survival compared with minimal follow-up, and more intensive surveillance may be costlier.OBJECTIVE:The purpose of this study was to estimate the quality-adjusted life-years, economic costs, and cost-effectiveness of various surveillance strategies after curative treatment of colon cancer.DESIGN:A Markov model was calibrated to reflect the natural history of colon cancer recurrence and used to estimate surveillance costs and outcomes.SETTINGS:This was a decision-analytic model.PATIENTS:Individuals entered the model at age 60 years after curative treatment for stage I, II, or III colon cancer. Other initial age groups were assessed in secondary analyses.MAIN OUTCOME MEASURES:We estimated the gains in quality-adjusted life-years achieved by early detection and treatment of recurrence, as well as the economic costs of surveillance under various strategies.RESULTS:Cost-effective strategies for patients with stage I colon cancer improved quality-adjusted life-expectancy by 0.02 to 0.06 quality-adjusted life-years at an incremental cost of $1702 to $13,019. For stage II, they improved quality-adjusted life expectancy by 0.03 to 0.09 quality-adjusted life-years at a cost of $2300 to $14,363. For stage III, they improved quality-adjusted life expectancy by 0.03 to 0.17 quality-adjusted life-years for a cost of $1416 to $17,631. At a commonly cited willingness-to-pay threshold of $100,000 per quality-adjusted life-year, the most cost-effective strategy for patients with a history of stage I or II colon cancer was liver ultrasound and chest x-ray annually. For those with a history of stage III colon cancer, the optimal strategy was liver ultrasound and chest x-ray every 6 months with CEA measurement every 6 months.LIMITATIONS:The study was limited by model structure assumptions and uncertainty around the values of the model's parameters.CONCLUSIONS:Given currently available data and within the limitations of a model-based decision-analytic approach, the effectiveness of routine intensive surveillance for patients after treatment of colon cancer appears, on average, to be small. Compared with testing using lower cost imaging, currently recommended strategies are associated with cost-effectiveness ratios that indicate low value according to well-accepted willingness-to-pay thresholds in the United States. See Video Abstract at http://links.lww.com/DCR/A921.

The relationship between emergency colon cancer resection and long-term oncological outcomes is not well understood. Our objective was to characterize the impact of emergency resection for colon cancer on disease-free and overall patient survival.

# 01. Laparoscopic splenectomy with management of intraoperative hemorrhage {#article-title-2} This video demonstrates a laparoscopic splenectomy for ITP with safe management of intraoperative hemorrhage. YouTube video link: [www.youtube.com/watch?v=6vYkOy3UePQ][1] # 02. Incisional hernia after

BACKGROUND:Programs of resident research have been found to improve research productivity. However, evidence of the success of these programs is lacking in a Canadian context. The objective of this study was to evaluate the impact of the introduction of a formal program of resident research at a single Canadian academic centre.METHODS:Resident research activities were tracked over a 10-year period (Resident Research Day (RRD) presentations, abstract presentations, published articles). Activities were divided into pre (2002-2007) and post (2007-2012) resident research program implementation time frames. Differences in research productivity were compared between time frames. Surveys of resident attitudes towards research were administered prior to the program's implementation in 2007, and following introduction of the resident research program in 2009 and 2015.RESULTS:Overall, research productivity (abstracts, publications, and RRD presentations) increased between pre and post resident research program time periods, with a statistically significant increase in mean number of published abstracts. Resident attitudes towards research changed somewhat over time, with fewer residents supporting mandatory research in recent years.CONCLUSION:Implementation of a resident program of research resulted in a significant increase in research productivity. The setting of clear, modifiable, and achievable goals, as well as providing tools for research success, have contributed to the success of this program.

BACKGROUND: Local resection for early rectal cancer is thought to be less invasive but oncologically inferior to radical resection.OBJECTIVE: The aim of this study was to compare local with radical resection in terms of oncologic control (survival and local recurrence), postoperative complications, and the need for a permanent stoma in adult patients with T1N0M0 rectal adenocarcinoma.DATA SOURCES: Data were retrieved from Medline, Embase, Central, www.clinicaltrials.gov, and conference proceedings.STUDY SELECTION: Two reviewers independently screened studies and assessed the risk of bias.INTERVENTIONS: Local resection (transanal procedures, excluding endoscopic polypectomy) versus radical resection were considered.MAIN OUTCOME MEASURES: The primary outcomes measured were overall survival, major postoperative complications, and the "need for permanent stoma."RESULTS: One randomized controlled trial and 12 observational studies contributed 2855 patients for analysis. The randomized controlled trial was inadequately powered. Observational study metaanalysis showed that local resection was associated with significantly lower 5-year overall survival (72 more deaths per 1000 patients; 95% CI 30-120). However, the transanal endoscopic microsurgery subgroup did not yield significantly lower overall survival than radical resection. Local resection was associated with higher local recurrence but with lower perioperative mortality (relative risk 0.31, 95% CI 0.14-0.71), major postoperative complications (relative risk 0.20, 95% CI 0.10-0.41), and need for a permanent stoma (relative risk 0.17, 95% CI 0.09-0.30). Findings were robust to sensitivity analyses. Meta-regression suggests that the higher overall survival associated with radical resection may be explained by increased use of local resection on tumors in the lower third of the rectum, which have poorer prognosis.LIMITATIONS: This systematic review of nonrandomized studies had inherent biases that may persist despite our rigorous use of systematic review methodology and sensitivity analyses.CONCLUSIONS: Local resection does not offer oncologic control comparable to radical surgery. However, this finding may be driven by the higher prevalence of cancers with poorer prognosis in local resection groups. Local resection is associated with lower postoperative complications, mortality, and the need for a permanent stoma. Local resection with transanal endoscopic microsurgery appears to offer oncologic control similar to that of radical resection while offering all the benefits of local resection.

BACKGROUND:Spin has been defined as "specific reporting that could distort the interpretation of results and mislead readers."OBJECTIVE:The purpose of this study was to identify how frequently, and to what extent, "spin" occurs in laparoscopic lower GI surgical trials with nonsignificant results.DATA SOURCES:Publications were referenced in MEDLINE and EMBASE (1992-2012).STUDY SELECTION:Randomized controlled trials comparing laparoscopic with open surgical technique in lower GI surgery were sought. Trials were included if a nonsignificant (p > 0.05) result of the primary outcome(s) occurred.INTERVENTION:The laparoscopic versus open technique in lower GI surgery was studied.MAIN OUTCOME MEASURES:Trials were assessed for frequency, strategy, and extent of "spin," as previously defined.RESULTS:Fifty-eight trials met the inclusion criteria. Sixty-six percent of these trials had evidence of "spin." In general, authors used significant results only (one of multiple primary outcomes, secondary outcomes, or subgroup analyses) (43%) or interpreted nonsignificance as equivalence (43%). Trials with spin were more likely to recommend the laparoscopic approach over the open technique (p < 0.001), were less likely to call for further trials (p = 0.003), and were less likely to acknowledge the nonsignificant differences (p < 0.001). Inadequate randomization was associated with decreased odds of spin (p = 0.03), as was an intent-to-treat analysis (p < 0.0001), whereas inadequate allocation concealment (p = 0.06) was weakly associated with a decrease in spin. No other a priori candidate risk factors were associated with the presence of spin.LIMITATIONS:Funding source was rarely described, so the association between industry funding and spin could not be assessed.CONCLUSION:The distortion of nonsignificant results in laparoscopic trials was highly prevalent in this review. Readers of trials with nonsignificant results should be cautious of the authors' interpretations. Editors, reviewers, and publishers should ensure that author's conclusions correspond to the study's results and design.

# 1 Is laparoscopic sleeve gastrectomy a reasonable stand-alone procedure for super morbidly obese patients? {#article-title-2} Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well established standard of care in the treatment of obesity and its associated comorbidities. Laparoscopic sleeve

It is well established that a diagnosis can be made solely on the basis of a patient’s history in the majority of cases. Physical examination may reveal more clues to the patient’s complaint, diagnostic tests are used to identify, assess, and confirm any physiological basis for disease. However, a thorough history and good clinical acumen contribute most to a medical diagnosis and treatment selection. This daunting idea is also reassuring, in that there is no substitute for a sound diagnostic approach that one can gain from experience. There is, however, always opportunity for a rare occurrence, a peculiar presentation, a proverbial ‘zebra’ to slip past our detection despite our most diligent efforts. Disguised by common or vague symptoms rather than stripes, these ‘zebras’ are a chance to step outside of the usual diagnostic process, summon a protracted differential diagnosis from our training, and regard an unsolved medical problem with new eyes. When the patterns of everyday medicine are broken by such a case, the importance of an astute doctor is starkly illuminated.

BACKGROUND To perform complete resection of locally advanced and recurrent rectal carcinoma, total pelvic exenteration (TPE) may be attempted. We identified disease-related outcomes and prognostic factors. METHODS We conducted a single-centre review of patients who underwent TPE for rectal carcinoma over a 10-year period. RESULTS We included 28 patients in our study. After a median follow-up of 35 months, 53.6% of patients were alive with no evidence of disease. The 3-year actuarial disease-free and overall survival rates were 52.2% and 75.1%, respectively. On univariate analysis, recurrent disease, preoperative body mass index greater than 30 and lymphatic invasion were poor prognostic factors for disease-free survival, and only lymphatic invasion predicted overall survival. Additionally, multivariate analysis identified lymphatic invasion as an independent poor prognostic factor for disease-free survival in this patient population with locally advanced and recurrent rectal carcinoma. CONCLUSION Despite the significant morbidity, TPE can provide long-term survival in patients with rectal carcinoma. Additionally, lymphatic invasion on final pathology was an independent prognostic factor for disease-free survival.

This study aimed to determine the effect of local anesthesia administered before laparoscopic surgery (preemptive anesthesia) on postoperative pain.