Publications by authors named "Chad G Ball"

350 Publications

The Perioperative Surgical Home, Enhanced Recovery After Surgery and how integration of these models may improve care for medically complex patients.

Can J Surg 2021 Jul 23;64(4):E381-E390. Epub 2021 Jul 23.

From the Department of Medicine, University of Calgary, Calgary, Alta. (Harrison, James, Ruzycki, Zarnke, Hemmelgarn); the Department of Community Health Sciences, University of Calgary, Calgary, Alta. (Harrison, James, Ronksley, Ruzycki, McRae, McCaughey, Dixon); the O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alta. (Ronksley, Zarnke, McCaughey, James); the Libin Cardiovascular Institute of Alberta, Cumming School of Medicine, University of Calgary, Calgary, Alta. (James); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle, Ball, Dixon); the Department of Emergency Medicine, University of Calgary, Calgary, Alta. (McRae); the Mazankowski Alberta Heart Institute, Edmonton, Alta. (Graham); and the Department of Medicine, University of Alberta, Edmonton, Alta. (Graham, Hemmelgarn).

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http://dx.doi.org/10.1503/cjs.002020DOI Listing
July 2021

Predatory publishing solicitation: a review of a single surgeon's inbox and implications for information technology resources at an organizational level.

Can J Surg 2021 06 9;64(3):E351-E357. Epub 2021 Jun 9.

From the Department of Surgery, University of Calgary, Calgary, Alta.

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http://dx.doi.org/10.1503/cjs.003020DOI Listing
June 2021

[Revues prédatrices : Sommes-nous face à un « univers alternatif »?]

Can J Surg 2021 Jun 9;64(3):E359-E360. Epub 2021 Jun 9.

Corédacteurs en chef, Journal canadien de chirurgie.

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http://dx.doi.org/10.1503/cjs.011021DOI Listing
June 2021

Predatory journal publishing: Is this an alternate universe?

Can J Surg 2021 Jun 9;64(3):E358. Epub 2021 Jun 9.

Coeditors, Canadian Journal of Surgery.

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http://dx.doi.org/10.1503/cjs.009821DOI Listing
June 2021

Don't Mess with the Pancreas! A Multicenter Analysis of the Management of Low-Grade Pancreatic Injuries.

J Trauma Acute Care Surg 2021 May 25. Epub 2021 May 25.

Introduction: Current guidelines recommend nonoperative management (NOM) of low-grade (AAST-OIS grade I-II) pancreatic injuries (LGPIs), and drainage rather than resection for those undergoing operative management, but they are based on low quality evidence. The purpose of this study was to review the contemporary management and outcomes of LGPIs and identify risk factors for morbidity.

Methods: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010-2018. The primary outcome was pancreas-related complications (PRCs). Predictors of PRCs were analyzed using multivariate logistic regression.

Results: 29 centers submitted data on 728 patients with LGPI (76% male; mean age 38; 37% penetrating; 51% grade I; median ISS 24). Among 24-hour survivors, definitive management was NOM in 31%, surgical drainage alone in 54%, resection in 10%, and pancreatic debridement or suturing in 5%. The incidence of PRCs was 21% overall, and was 42% after resection, 26% after drainage, and 4% after NOM. On multivariate analysis, independent risk factors for PRC were other intra-abdominal injury (OR 2.30; 1.16, 15.28), low volume (OR 2.88; 1.65, 5.06), and penetrating injury (OR 3.42; 1.80, 6.58). Resection was very close to significance (OR 2.06; 0.97, 4.34) (p = 0.0584).

Conclusion: The incidence of PRCs is significant after LGPIs. Patients who undergo pancreatic resection have PRC rates equivalent to patients resected for HGPIs. Those who underwent surgical drainage had slightly lower PRC rate, but only 4% of those who underwent NOM had PRCs. In patients with LGPIs, resection should be avoided. The NOM strategy should be employed whenever possible and studied prospectively, particularly in penetrating trauma.

Level Of Evidence: Level III, Retrospective Diagnostic/Therapeutic Study.
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http://dx.doi.org/10.1097/TA.0000000000003293DOI Listing
May 2021

Real-World Outcomes of Oxaliplatin-Based Chemotherapy on R0 Resected Colonic Liver Metastasis.

Clin Colorectal Cancer 2021 Apr 20. Epub 2021 Apr 20.

Department of Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, AB, Canada.

Introduction: In resected colonic liver metastasis (CLM), randomized studies of oxaliplatin-based chemotherapy have demonstrated improvements in disease-free survival (DFS), but not overall survival (OS). Additionally, oxaliplatin regimens have not been compared to non-oxaliplatin chemotherapy. Despite limited evidence, perioperative chemotherapy is often used in the management of CLM. The primary aim of this study was to assess the impact of oxaliplatin chemotherapy regimens on OS in patients who have undergone resection of CLM in a real-world setting.

Patients And Methods: Patients who underwent resection of CLM in the provinces of Alberta and British Columbia, Canada, were identified from 1996 to 2016. Perioperative (pre- and/or post-) systemic therapy was categorized as oxaliplatin or non-oxaliplatin-based chemotherapy or no chemotherapy. The primary and secondary outcomes were OS and DFS, respectively.

Results: We identified 511 patients who underwent R0 resection of CLM. A significant difference in median OS was identified among the oxaliplatin, non-oxaliplatin, and no-chemotherapy groups of 100, 60, and 59 months, respectively (P = .009). In multivariate analysis, patients who received oxaliplatin regimens had a lower risk of death (hazard ratio, 0.68; 95% confidence interval, 0.51-0.92; P = .012), whereas the non-oxaliplatin chemotherapy group did not (hazard ratio, 0.88; 95% confidence interval, 0.65-1.20; P = .422) compared with no chemotherapy.

Conclusions: In this multicenter, retrospective, population-based study, perioperative oxaliplatin-based chemotherapy was associated with improved OS in conjunction with R0 resection of CLM. Further studies should evaluate the optimal duration and sequencing of perioperative chemotherapy in relation to curative-intent surgical resection of CLM.
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http://dx.doi.org/10.1016/j.clcc.2021.04.004DOI Listing
April 2021

THE ART AND CRAFT OF BILIARY T-TUBE USE.

J Trauma Acute Care Surg 2021 May 5. Epub 2021 May 5.

Department of Surgery, University of Calgary.

Introduction: Since the universal adoption of Hans Kehr's biliary T-tube in the early twentieth century, use has shifted from routine towards highly selective. Improved interventional endoscopy, percutaneous techniques, and hepato-pancreato-biliary (HPB) training have resulted in less T-tube experience within general surgery. The aim of this technical review is to discuss T-tube indications, technical nuances, and management.

Methods: Peer-reviewed literature, combined with high volume HPB experience by the authors, was utilized to construct a 10-step conceptual pathway for safe T-tube usage.

Results: Essential concepts surrounding T-tube use include: 1. Contemporary indications for T-tube insertion (disease-, patient-, and anatomy-based); 2. Correct instrument availability (open and laparoscopic); 3. T-tube selection and mechanical preparation; 4. Atraumatic T-tube insertion and security; 5. Immediate postoperative management and meticulous T-tube care; 6. Imaging biliary T-tubes; 7. Optimal timing of T-tube removal; 8. Technical aspects of T-tube removal; 9. Management of potential T-tube inpatient complications; and 10. Management of T-tube complications in the outpatient setting.

Conclusions: Although their use has decreased substantially, the role of biliary T-tubes in some patients is essential. Given the reality of less frequent experience with T-tube insertion and management, this 10-step pathway will provide an adequate mental and technical framework for safe biliary T-tube use.

Level Of Evidence: Level V, Expert opinion.
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http://dx.doi.org/10.1097/TA.0000000000003267DOI Listing
May 2021

Response to: Comment on Preoperative single-dose Methylprednisolone Prevents Surgical Infections after Major Liver Resection: A randomized controlled trial.

Ann Surg 2021 Apr 30. Epub 2021 Apr 30.

Department of Surgery, University of Calgary, Calgary, Alberta, Canada Department of Surgery, University of Calgary, Calgary, Alberta, Canada Department of Surgery, University of Calgary, Calgary, Alberta, Canada Department of Surgery, University of Calgary, Calgary, Alberta, Canada Department of Surgery, University of Calgary, Calgary, Alberta, Canada Department of Surgery, University of Calgary, Calgary, Alberta, Canada.

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http://dx.doi.org/10.1097/SLA.0000000000004919DOI Listing
April 2021

The effect of high intraoperative blood loss on pancreatic fistula development after pancreatoduodenectomy: An international, multi-institutional propensity score matched analysis.

Surgery 2021 Apr 27. Epub 2021 Apr 27.

Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Electronic address:

Background: The association between intraoperative estimated blood loss and outcomes after pancreatoduodenectomy has, thus far, been rarely explored.

Methods: In total, 7,706 pancreatoduodenectomies performed at 18 international institutions composing the Pancreas Fistula Study Group were examined (2003-2020). High estimated blood loss (>700 mL) was defined as twice the median. Propensity score matching (1:1 exact-match) was employed to adjust for variables associated with high estimated blood loss and clinically relevant pancreatic fistula occurrence. The study was powered to detect a 33% clinically relevant pancreatic fistula increase in the high estimated blood loss group, with α = 0.05 and β = 0.2.

Results: The propensity score model included 966 patients with high estimated blood loss and 966 patients with lower estimated blood loss; all covariate imbalantces were solved. Patients with high estimated blood loss patients experienced higher clinically relevant pancreatic fistula rates (19.4 vs 12.6%, odds ratio 1.66; P < .001), as well as higher severe complication rates (27.8 vs 15.6%), transfusions (50.1 vs 14.3%), reoperations (9.2 vs 4.0%), intensive care unit transfers (9.9 vs 4.8%) and 90-day mortality (4.7 vs 2.0%, all P < .001). High estimated blood loss was an independent predictor for clinically relevant pancreatic fistula (odds ratio 1.78, 95% confidence interval 1.37-2.32), as were prophylactic Octreotide administration (odds ratio 1.95, 95% confidence interval 1.46-2.61) and soft pancreatic texture (odds ratio 5.32, 95% confidence interval 3.74-5.57; all P < .001). Moreover, a second model including 1,126 pancreatoduodenectomies was derived including vascular resections as additional confounder (14.0% vascular resections performed in each group). On multivariable regression, high estimated blood loss was confirmed an independent predictor for clinically relevant pancreatic fistula reduction (odds ratio 1.80, 95% confidence interval 1.32-2.44; P < .001), whereas vascular resection was not (odds ratio 0.64, 95% confidence interval 0.34-1.88; P = .156).

Conclusion: This study better establishes the relationship between estimated blood loss and outcomes after pancreatoduodenectomy. Despite inherent contributions to blood loss, its minimization is an actionable opportunity for clinically relevant pancreatic fistula reduction and performance optimization in pancreatoduodenectomy. Accordingly, practical insights are offered to achieve this goal.
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http://dx.doi.org/10.1016/j.surg.2021.03.044DOI Listing
April 2021

A multicenter trial of current trends in the diagnosis and management of high-grade pancreatic injuries.

J Trauma Acute Care Surg 2021 05;90(5):776-786

From the Scripps Memorial Hospital La Jolla (WLB, FZZ, MC, KBS), La Jolla, CA; Maine Medical Center (BM), Portland, ME; Memorial Hermann Hospital (MM), Houston, TX; University of Oklahoma (JL), Oklahoma City, OK; Ryder Trauma Center (SB), Miami, FL; University of California-San Diego (JW), San Diego, CA; San Francisco General Hospital (RC, LK), San Francisco, CA; University of Calgary (CCGB), Calgary, Alberta, Canada; University of California-Irvine (JN), Irvine, CA; North Memorial Health Hospital (MW), Robbinsdale, MN; University of California-Davis (GJJ), Sacramento, CA; Grady Memorial Hospital (SRT), Atlanta, GA; Hadassah- Hebrew University Medical Center (MB), Jerusalem, Israel; Grant Medical Center (CS), Columbus, OH; Ernest E. Moore Shock Trauma Center at Denver Health (EEM), Denver, CO.

Background: Outcomes following pancreatic trauma have not improved significantly over the past two decades. A 2013 Western Trauma Association algorithm highlighted emerging data that might improve the diagnosis and management of high-grade pancreatic injuries (HGPIs; grades III-V). We hypothesized that the use of magnetic resonance cholangiopancreatography, pancreatic duct stenting, operative drainage versus resection, and nonoperative management of HGPIs increased over time.

Methods: Multicenter retrospective review of diagnosis, management, and outcomes of adult pancreatic injuries from 2010 to 2018 was performed. Data were analyzed by grade and time period (PRE, 2010-2013; POST, 2014-2018) using various statistical tests where appropriate.

Results: Thirty-two centers reported data on 515 HGPI patients. A total of 270 (53%) had penetrating trauma, and 58% went directly to the operating room without imaging. Eighty-nine (17%) died within 24 hours. Management and outcomes of 426 24-hour survivors were evaluated. Agreement between computed tomography and operating room grading was 38%. Magnetic resonance cholangiopancreatography use doubled in grade IV/V injuries over time but was still low.Overall HGPI treatment and outcomes did not change over time. Resection was performed in 78% of grade III injuries and remained stable over time, while resection of grade IV/V injuries trended downward (56% to 39%, p = 0.11). Pancreas-related complications (PRCs) occurred more frequently in grade IV/V injuries managed with drainage versus resection (61% vs. 32%, p = 0.0051), but there was no difference in PRCs for grade III injuries between resection and drainage.Pancreatectomy closure had no impact on PRCs. Pancreatic duct stenting increased over time in grade IV/V injuries, with 76% used to treat PRCs.

Conclusion: Intraoperative and computed tomography grading are different in the majority of HGPI cases. Resection is still used for most patients with grade III injuries; however, drainage may be a noninferior alternative. Drainage trended upward for grade IV/V injuries, but the higher rate of PRCs calls for caution in this practice.

Level Of Evidence: Retrospective diagnostic/therapeutic study, level III.
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http://dx.doi.org/10.1097/TA.0000000000003080DOI Listing
May 2021

The Primary Spontaneous Pneumothorax trial: A critical appraisal from the surgeon's perspective.

J Thorac Cardiovasc Surg 2021 Feb 24. Epub 2021 Feb 24.

Department of Surgery, University of Calgary, Calgary, Alberta, Canada.

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http://dx.doi.org/10.1016/j.jtcvs.2021.02.070DOI Listing
February 2021

Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review.

World J Emerg Surg 2021 Mar 11;16(1):10. Epub 2021 Mar 11.

Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada.

Background: Although damage control (DC) surgery is widely assumed to reduce mortality in critically injured patients, survivors often suffer substantial morbidity, suggesting that it should only be used when indicated. The purpose of this systematic review was to determine which indications for DC have evidence that they are reliable and/or valid (and therefore in which clinical situations evidence supports use of DC or that DC improves outcomes).

Methods: We searched 11 databases (1950-April 1, 2019) for studies that enrolled exclusively civilian trauma patients and reported data on the reliability (consistency of surgical decisions in a given clinical scenario) or content (surgeons would perform DC in that clinical scenario or the indication predicted use of DC in practice), construct (were associated with poor outcomes), or criterion (were associated with improved outcomes when DC was conducted instead of definitive surgery) validity for suggested indications for DC surgery or DC interventions.

Results: Among 34,979 citations identified, we included 36 cohort studies and three cross-sectional surveys in the systematic review. Of the 59 unique indications for DC identified, 10 had evidence of content validity [e.g., a major abdominal vascular injury or a packed red blood cell (PRBC) volume exceeding the critical administration threshold], nine had evidence of construct validity (e.g., unstable patients with combined abdominal vascular and pancreas gunshot injuries or an iliac vessel injury and intraoperative acidosis), and six had evidence of criterion validity (e.g., penetrating trauma patients requiring > 10 U PRBCs with an abdominal vascular and multiple abdominal visceral injuries or intraoperative hypothermia, acidosis, or coagulopathy). No studies evaluated the reliability of indications.

Conclusions: Few indications for DC surgery or DC interventions have evidence supporting that they are reliable and/or valid. DC should be used with respect for the uncertainty regarding its effectiveness, and only in circumstances where definitive surgery cannot be entertained.
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http://dx.doi.org/10.1186/s13017-021-00352-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7951941PMC
March 2021

Evaluations for New Healthcare Environment Commissioning and Operational Decision Making Using Simulation and Human Factors: A Case Study of an Interventional Trauma Operating Room.

HERD 2021 Mar 11:1937586721999668. Epub 2021 Mar 11.

Alberta Health Services, Calgary, Alberta, Canada.

Purpose: The aim of this article is to provide a case study example of the preopening phase of an interventional trauma operating room (ITOR) using systems-focused simulation and human factor evaluations for healthcare environment commissioning.

Background: Systems-focused simulation, underpinned by human factors science, is increasingly being used as a quality improvement tool to test and evaluate healthcare spaces with the stakeholders that use them. Purposeful real-to-life simulated events are rehearsed to allow healthcare teams opportunity to identify what is working well and what needs improvement within the work system such as tasks, environments, and processes that support the delivery of healthcare services. This project highlights salient evaluation objectives and methods used within the clinical commissioning phase of one of the first ITORs in Canada.

Methods: A multistaged evaluation project to support clinical commissioning was facilitated engaging 24 stakeholder groups. Key evaluation objectives highlighted include the evaluation of two transport routes, switching of operating room (OR) tabletops, the use of the C-arm, and timely access to lead in the OR. Multiple evaluation methods were used including observation, debriefing, time-based metrics, distance wheel metrics, equipment adjustment counts, and other transport route considerations.

Results: The evaluation resulted in several types of data that allowed for informed decision making for the most effective, efficient, and safest transport route for an exsanguinating trauma patient and healthcare team; improved efficiencies in use of the C-arm, significantly reduced the time to access lead; and uncovered a new process for switching OR tabletop due to safety threats identified.
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http://dx.doi.org/10.1177/1937586721999668DOI Listing
March 2021

OPTICC: A multicentre trial of Occult Pneumothoraces subjected to mechanical ventilation: The final report.

Am J Surg 2021 06 20;221(6):1252-1258. Epub 2021 Feb 20.

Department of Surgery, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada; The Trauma Program, Foothills Medical Centre, Calgary, Alberta, Canada; Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada; Canadian Forces Medical Services, Ottawa, Ontario, Canada. Electronic address:

Introduction: Patients with occult pneumothorax (OPTX) requiring positive-pressure ventilation (PPV) face uncertain risks of tension pneumothorax or chest drainage complications.

Methods: Adults with traumatic OPTXs requiring PPV were randomized to drainage/observation, with the primary outcome of composite "respiratory distress" (RD)).

Results: Seventy-five (75) patients were randomized to observation, 67 to drainage. RD occurred in 38% observed and 25% drained (p = 0.14; Power = 0.38), with no mortality differences. One-quarter of observed patients failed, reaching 40% when ventilated >5 days. Twenty-three percent randomized to drainage had complications or ineffectual drains.

Conclusion: RD was not significantly different with observation. Thus, OPTXs may be cautiously observed in stable patients undergoing short-term PPV when prompt "rescue drainage" is immediately available. As 40% of patients undergoing prolonged (≥5 days) ventilation (PPPV) require drainage, we suggest consideration of chest drainage performed with expert guidance to reduce risk of chest tube complications.

Level Of Evidence: Therapeutic study, level II.
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http://dx.doi.org/10.1016/j.amjsurg.2021.02.012DOI Listing
June 2021

Time to operating room matters in modern management of pancreatic injuries: A national review on the management of adult pancreatic injury at Canadian level 1 trauma centers.

J Trauma Acute Care Surg 2021 03;90(3):434-440

From the Division of General Surgery/Department of Surgery (E.J., M.S.H.), University of British Columbia, Vancouver; University of Groningen (N.d.J.), Faculty of Medicine; Department of Surgery (C.G.B., S.Q.), University of Calgary, Calgary; Department of Surgery (V.T., M.M.), Laval University, Québec City; Department of Surgery (P.T.E.), McMaster University, Hamilton; Department of Surgery (J.R.), University of Saskatchewan, Regina; Department of Surgery (L.M.G., R.V.), University of Manitoba, Winnipeg; Department of Surgery (S.W.), University of Alberta, Edmonton; and Department of Surgery (K.N.V.), Western University, London, Canada.

Background: Pancreatic injuries are rare, difficult to diagnose, and complex to manage despite multiple published guidelines. This study was undertaken to evaluate the current diagnosis and management of pancreatic trauma in Canadian trauma centers.

Methods: This is a multi-institutional retrospective study from 2009 to 2014 including patients from eight level 1 trauma centers across Canada. All patients with a diagnosis of pancreatic trauma were included. Demographics, injury characteristics, vital signs on admission, and type of management were collected. Outcomes measured were mortality and pancreas-related morbidity.

Results: Two hundred seventy-nine patients were included. The median age was 29 years (interquartile range, 21-43 years), 72% were male, and 79% sustained blunt trauma. Pancreatic injury included the following grades: I, 26%; II, 28%; III, 33%; IV, 9%; and V, 4%. The overall mortality rate was 11%, and the pancreas-related complication rate was 25%. The majority (88%) of injuries were diagnosed within 24 hours of injury, primarily (80%) with a computed tomography scan. The remaining injuries were diagnosed with ultrasound (6%) and magnetic resonance cholangiopancreatography (MRCP) (2%) and at the time of laparotomy or autopsy (12%). One hundred seventy-five patients (63%) underwent an operative intervention, most commonly a distal pancreatectomy (44%); however, there was great variability in operative procedure chosen even when considering grade of injury.

Conclusion: Pancreatic injuries are associated with multiple other injuries and have significant morbidity and mortality. Their management demonstrates significant practice variation within a national trauma system.

Level Of Evidence: Therapeutic/care management, level V; Prognostic and epidemiological, level IV.
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http://dx.doi.org/10.1097/TA.0000000000003025DOI Listing
March 2021

Is an optical illusion the cause of classical bile duct injuries?

Can J Surg 2021 01 7;64(1):E1-E2. Epub 2021 Jan 7.

From the Department of Surgery (Sutherland, Ball, Schendel, Dixon), University of Calgary, Calgary, Alta.

We sought to determine if lateral-inferior traction on the Hartmann pouch could produce bile duct kinking and subsequent misinterpretation of the space on the left side of the bile duct as the hepatobiliary triangle. Once traction was applied, we measured the angle between the cystic duct and inferior gallbladder wall hepatobiliary triangle) in 76 cases, and the angle between the common bile duct and common hepatic duct (porta hepatis "triangle") in 41 cases. The mean angles were significantly different (hepatobiliary triangle mean 68.2°, standard deviation [SD] 16.0°, range 23-109°; porta hepatis "triangle" mean 112.0°, SD 18.4°, range 72-170°; p < 0.01). The ranges, however, overlapped in 26 cases. In many cases, lateral-inferior traction on the Hartmann pouch produced substantial kinking of the bile duct that could easily elicit the illusion that it is the hepatobiliary triangle rather than the centre of the porta hepatis.
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http://dx.doi.org/10.1503/cjs.014019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955820PMC
January 2021

Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development.

Surgery 2021 04 30;169(4):708-720. Epub 2020 Dec 30.

Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA. Electronic address:

Background: Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood.

Methods: The fistula risk score was applied to identify high-risk patients (fistula risk score 7-10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003-2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models.

Results: Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (-49.7%) and career length (-41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35-0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22-0.74).

Conclusion: Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.
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http://dx.doi.org/10.1016/j.surg.2020.11.022DOI Listing
April 2021

Preoperative Single-Dose Methylprednisolone Prevents Surgical Site Infections After Major Liver Resection: A Randomized Controlled Trial.

Ann Surg 2020 Dec 18;Publish Ahead of Print. Epub 2020 Dec 18.

Departments of Surgery, University of Calgary, Calgary, Alberta, Canada.

Objective: The primary aim of this study was to evaluate the efficacy of a single preoperative dose of methylprednisolone for preventing postoperative complications after major liver resections.

Summary Background Data: Hepatic resections are associated with a significant acute systemic inflammatory response. This effect subsequently correlates with postoperative morbidity, mortality and length of recovery. Multiple small trials have proposed that the administration of glucocorticoids may modulate this effect.

Methods: This study was a parallel, dual-arm, double-blind randomized controlled trial. Adult patients undergoing elective major hepatic resection (≥3 segments) at a quaternary care institution were included (2013-2019). Patients were randomly assigned to receive a single preoperative 500 mg dose of methylprednisolone versus placebo. The main outcome measure was postoperative complications after liver resection, within 90 days of the index operation. Standard statistical methodology was employed (p < 0.05 = significant).

Results: A total of 151 patients who underwent a major hepatic resection were randomized (mean age = 62.8 years; 57% male; body-mass-index = 27.9). No significant differences were identified between the intervention and control groups (age, sex, body-mass-index, preoperative comorbidities, hepatic function, ASA class, portal vein embolization rate)(p > 0.05). Underlying hepatic diagnoses included colorectal liver metastases (69%), hepatocellular carcinoma (18%), non-colorectal liver metastases (7%), and intrahepatic cholangiocarcinoma (6%). There was a significant reduction in the overall incidence of postoperative complications in the methylprednisolone group (31.2% vs. 47.3%; p = 0.042). Patients in the glucocorticoid group also displayed less frequent organ space surgical site infections (6.5% vs. 17.6%; p = 0.036), as well as a shorter length of hospital stay (8.9 vs. 12.5 days; p = 0.015). Postoperative serum bilirubin and prothrombin time-international normalized ratio (PT-INR) levels were also lower in the steroid group (p = 0.03 and 0.04 respectively). Multivariate analysis did not identify any additional significant modifying factor relationships (estimated blood loss, duration of surgery, hepatic vascular occlusion (rate or duration), portal vein embolization, drain use, etc.)(p > 0.05).

Conclusions: A single preoperative dose of methylprednisolone significantly reduces the length of hospital stay, postoperative serum bilirubin and PT-INR, as well as infectious and overall complications following major hepatectomy.
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http://dx.doi.org/10.1097/SLA.0000000000004720DOI Listing
December 2020

Effect of wound protectors on surgical site infection in patients undergoing whipple procedure.

HPB (Oxford) 2020 Dec 15. Epub 2020 Dec 15.

University of Calgary, Department of Surgery, Calgary, AB, Canada.

Background: Conflicting data persists for use of wound protectors in pancreatoduodenectomy (PD) to prevent surgical site infection (SSI). We aimed to examine, at a multi-institutional level, the effect of wound protectors on superficial or deep SSI following elective open PD.

Methods: The American College of Surgeons National Surgical Quality Improvement Program pancreatectomy procedure targeted participant use file was queried from 2016 to 2018. Planned open PD procedures were extracted. Univariable, multivariable, and propensity score matched analyses were conducted.

Results: 11,562 patients undergoing PD were evaluated, 27% of which used wound protectors. Wound protectors decreased superficial or deep SSI risk in all patients (5.7% vs. 9.5%, P < 0.001), patients who have (6.6% vs. 12.2%, P < 0.001) and who did not have (4.6% vs. 6.5%, P = 0.011) a biliary stent. Propensity score matched analysis confirms such results (OR = 0.56, 95% CI: 0.46-0.69, P < 0.001 overall, OR = 0.66, 95% CI: 0.46-0.95, P = 0.03 without biliary stent, OR = 0.57, 95% CI: 0.44-0.73, P < 0.001 with biliary stent).

Conclusions: Wound protectors reduce risk of superficial or deep SSI in patients undergoing PD, yet only a quarter of PD were associated with their use. This protective effect is seen whether patients have or have not had preoperative biliary stenting.
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http://dx.doi.org/10.1016/j.hpb.2020.11.1146DOI Listing
December 2020

Do we need to reassess the meaning of "team" in our health care environments?

Can J Surg 2020 12 9;63(6):E594-E595. Epub 2020 Dec 9.

Coeditors in chief, Canadian Journal of Surgery (Ball, Harvey); the Department of Surgery, University of Calgary, Calgary, Alta. (Ball); the Department of Surgery, McGill University, Montreal, Que.(Harvey); and the Department of Anesthesiology, University of Calgary, Calgary, Alta. (Davis).

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http://dx.doi.org/10.1503/cjs.022620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747843PMC
December 2020

Do we have the guts to go? The abdominal compartment, intra-abdominal hypertension, the human microbiome and exploration class space missions.

Can J Surg 2020 Nov-Dec;63(6):E581-E593

From the Tele-Mentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group Collaborators; Departments of Medicine and Engineering, University of Calgary, Calgary, Alta. (Kirkpatrick, Hamilton, McKee); the Departments of Critical Care Medicine and Medicine, Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, Alta. (MacDonald); the Department of Surgical Sciences and Integrated Diagnostics, University of Genoa; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy (Pelosi); Regional Trauma Services; Departments of Surgery and Critical Care Medicine, University of Calgary, Calgary, Alta. (Ball); the Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, Ottawa, Ont. (Roberts); the Tele-Mentored Ultrasound Supported Medical Interventions (TMUSMI) Research Group Collaborators; Regional Trauma Services; Foothills Medical Centre; Departments of Engineering, Surgery and Critical Care Medicine, University of Calgary, Calgary, Alta. (McBeth); the Departments of Trauma and Emergency Surgery, Pisa University Hospital, Pisa, Italy (Cocolini); the Departments of General, Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy (Ansaloni); the Division of Trauma Surgery, University of Campinas, Campinas, São Paulo, Brazil (Peireira); the Department of Surgery, Letterkenny University Hospital, Letterkenny, Donegal, Ireland (Sugrue); the Paris Regional Medical Centre, Paris, Texas, United States (Campbell); the Departments of Surgery and Critical Care, Network Development and Telehealth, University of Utah, Salt Lake City, US (Kimball); the Faculties of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium (Malbrain).

Humans are destined to explore space, yet critical illness and injury may be catastrophically limiting for extraterrestrial travel. Humans are superorganisms living in symbiosis with their microbiomes, whose genetic diversity dwarfs that of humans. Symbiosis is critical and imbalances are associated with disease, occurring within hours of serious illness and injury. There are many characteristics of space flight that negatively influence the microbiome, especially deep space itself, with its increased radiation and absence of gravity. Prolonged weightlessness causes many physiologic changes that are detrimental; some resemble aging and will adversely affect the ability to tolerate critical illness or injury and subsequent treatment. Critical illness-induced intra-abdominal hypertension (IAH) may induce malperfusion of both the viscera and microbiome, with potentially catastrophic effects. Evidence from animal models confirms profound IAH effects on the gut, namely ischemia and disruption of barrier function, mechanistically linking IAH to resultant organ dysfunction. Therefore, a pathologic dysbiome, space-induced immune dysfunction and a diminished cardiorespiratory reserve with exacerbated susceptibility to IAH, imply that a space-deconditioned astronaut will be vulnerable to IAH-induced gut malperfusion. This sets the stage for severe gut ischemia and massive biomediator generation in an astronaut with reduced cardiorespiratory/immunological capacity. Fortunately, experiments in weightless analogue environments suggest that IAH may be ameliorated by conformational abdominal wall changes and a resetting of thoracoabdominal mechanics. Thus, review of the interactions of physiologic changes with prolonged weightlessness and IAH is required to identify appropriate questions for planning exploration class space surgical care.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747844PMC
February 2021

Invasive fungal infection requiring explantation of a noncrosslinked porcine derived biologic mesh: a rare but catastrophic complication in abdominal wall reconstruction.

Can J Surg 2020 Nov-Dec;63(6):E533-E536

From the University of Calgary, Cumming School of Medicine, Calgary, Alta. (Ober, Nickerson, Caragea, Ball, Kirkpatrick); the Department of Surgery, University of Calgary, Calgary, Alta. (Nickerson, Ball, Kirkpatrick); the Department of Pathology, University of Calgary, Calgary, Alta. (Caragea); and the Department of Critical Care Medicine, University of Calgary, Calgary, Alta. (Kirkpatrick).

Summary: Biologic mesh is preferred over synthetic mesh for complex and contaminated abdominal wall repairs; however, there are very little data on the risks and complications associated with its use. We report the case of a 67-year-old man with failed synthetic mesh repair for recurrent ventral hernia, who subsequently required an abdominal wall reconstruction (AWR), including the intraperitoneal sublay of noncrosslinked biologic mesh. His postoperative course was complicated with catastrophic sepsis and sustained hemodynamic instability, responding only to mesh explantation. The biologic mesh was subsequently noted to be histologically infected with invasive . Although noncrosslinked biologic mesh is a valuable adjunct to AWR, it is not infection-resistant. Although it is rare, infection of any foreign tissue, including biologic mesh, can occur in the setting of complex ventral abdominal wall repairs. Clinicians should be watchful for such infections in complex repairs as they may require biologic mesh explantation for clinical recovery.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7747838PMC
February 2021

The Influence of Intraoperative Blood Loss on Fistula Development Following Pancreatoduodenectomy.

Ann Surg 2020 Nov 12. Epub 2020 Nov 12.

Departments of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.

Objective: To investigate the role of intraoperative EBL on development of CR-POPF after pancreatoduodenectomy (PD).

Background: Minimizing EBL has been shown to decrease transfusions and provide better perioperative outcomes in PD. EBL is also felt to be influential on CR-POPF development.

Methods: This study consists of 5534 PDs from a 17-institution collaborative (2003-2018). EBL was progressively categorized (≤150 mL; 151-400 mL; 401-1,000 mL; >1,000 mL). Impact of additive EBL was assessed using 20 3-factor fistula risk score (FRS) scenarios reflective of endogenous CR-POPF risk.

Results: CR-POPF developed in 13.6% of patients (N = 753) and median EBL was 400 mL (interquartile range 250-600 mL). CR-POPF and Grade C POPF were associated with elevated EBL (median 350 vs 400 mL, P = 0.002; 372 vs 500 mL, P < 0.001, respectively). Progressive EBL cohorts displayed incremental CR-POPF rates (8.5%, 13.4%, 15.2%, 16.9%; P < 0.001). EBL >400 mL was associated with increased CR-POPF occurrence in 13/20 endogenous risk scenarios. Moreover, 8 of 10 scenarios predicated on a soft gland demonstrated increased CR-POPF incidence. Hypothetical projections demonstrate significant reductions in CR-POPF can be obtained with 1-, 2-, and 3-point decreases in FRS points attributed to EBL risk (12.2%, 17.4%, and 20.0%; P < 0.001). This is especially pronounced in high-risk (FRS7-10) patients, who demonstrate up to a 31% reduction (P < 0.001). Surgeons in the lowest-quartile of median EBL demonstrated CR-POPF rates less than half those in the upper-quartile (7.9% vs 18.8%; P < 0.001).

Conclusion: EBL independently contributes significant biological risk to CR-POPF. Substantial reductions in CR-POPF occurrence are projected and obtainable by minimizing EBL. Decreased individual surgeon EBL is associated with improvements in CR-POPF.
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http://dx.doi.org/10.1097/SLA.0000000000004549DOI Listing
November 2020

Patterns of complex emergency general surgery in Canada.

Can J Surg 2020 Sep-Oct;63(5):E435-E441

From the Division of General Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ont. (Vogt, Allen, Murphy, Parry); the Division of General Surgery, Department of Surgery, William Osler Health System, Brampton, Ont. (Van Heest, Saleh); the Division of General Surgery, Department of Surgery, University of Alberta, Edmonton, Alta. (Widder); the Divisions of General Surgery and Critical Care Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, N.S. (Minor, Lacoul); the Department of Surgery Hamilton General Hospital, McMaster University, Hamilton, Ont. (Engels, Nenshi, Meschino); the Division of Trauma and Acute Care Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, B.C. (Joos, Laane, Hameed); and the Divisions of Surgery and Oncology, University of Calgary, Calgary, Alta. (Ball).

Background: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada.

Methods: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality.

Results: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age ( = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre ( = 0.001).

Conclusion: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608705PMC
November 2020

Optimal treatments for hepato-pancreato-biliary trauma in severely injured patients: a narrative scoping review.

Can J Surg 2020 Sep-Oct;63(5):E431-E434

From the Department of Surgery, University of Calgary, Calgary, Alta. (Streith, Silverberg, Kirkpatrick, Bathe, Ball); and the Department of Surgery, University of British Columbia, Vancouver, BC (Hameed).

Summary: Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608711PMC
November 2020
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