Janice Montbriand

Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: Preliminary outcomes from the Toronto General Hospital Transitional Pain Service

ABSTRACT Background: Chronic postsurgical pain (CPSP) and associated long-term opioid use are major public health concerns. Aims: The Toronto General Hospital Transitional Pain Service (TPS) is a multidisciplinary, hospital-integrated program developed to prevent and manage CPSP and support opioid tapering. This clinical practice–based study reports on preliminary outcomes of the TPS psychology program, which provides acceptance and commitment therapy (ACT) to patients at risk for CPSP and persistent opioid use. Methods: Ninety-one patients received ACT, whereas 252 patients did not (no ACT group). Patient outcomes were compared for the two groups at first and last TPS visits. Pain, pain interference, sensitivity to pain traumatization, pain catastrophizing, anxiety, depression, and opioid use were analyzed using two-way (Group [ACT, no ACT] × Time [first, last visit]) analyses of variance (ANOVAs). Results: Patients referred to ACT were more likely to report a mental health condition preoperatively (P < 0.001), had higher opioid use (P < 0.001) at the first postsurgical visit, and reported higher sensitivity to pain traumatization (P < 0.05) and anxiety (P < 0.05) than the no ACT group at both time points. Both groups showed reductions in pain, pain interference, pain catastrophizing, anxiety, and opioid use by the last TPS visit (P < 0.05). The ACT group demonstrated greater reductions in opioid use and pain interference and showed reductions in depressed mood (P = 0.001) by the end of treatment compared to the no ACT group. Conclusion: Preliminary outcomes suggest that ACT was effective in reducing opioid use while pain interference and mood improved.

Outcomes of minor amputations in patients with peripheral vascular disease over a 10-year period at a tertiary care institution

Objectives Choosing an optimal amputation level requires balance between maximizing limb salvage while minimizing chances of non-healing wounds and re-amputation. Our aim was to assess the long-term outcome for minor amputations in patients with peripheral vascular disease. Methods A retrospective study of minor amputations between January 1, 2005 and December 31, 2015 was performed. Electronic medical records of eligible patients were examined to extract demographics, co morbidities and clinical data. Results Within the study period, 220 patients underwent 296 primary minor amputations in 244 lower extremities. Wound healing was achieved in 18.2% (54 of 296 amputations) and 43.6% (129 of 296 amputations) at 90 days and 365 days, respectively. Rates of progression to major amputation were 16.4% (40 or 244 limbs) and 21.7% (53 of 244 limbs) at 90 days and 365 days, respectively. In the final multivariate model, lower ipsilateral posterior tibial waveforms predicted poor 90-day healing (OR = 2.22, p = 0.01) as well as limb loss (OR = 3.02, p = 0.02) in a dose-response manner. In the final logistic regression model, emergency department admission (OR = 0.20, p < 0.01), ipsilateral posterior tibial waveform (OR = 2.63, p < 0.01), and post-operative infection (OR = 0.30, p < 0.01) were predictors of poor healing status at study endpoint. Conclusion This study shows that a majority of foot amputees require ongoing care for non-healing wounds and a proportion necessitate conversion to major amputation. Adequate vascularization is essential to promote and maintain healing.

Smoking, pain intensity, and opioid consumption one to three months after major surgery: A retrospective study in a hospital-based Transitional Pain Service.

Introduction The present study investigated the associations between smoking, pain, and opioid consumption in the 3 months after major surgery in patients seen by the Transitional Pain Service. Current smoking status and lifetime pack-years were expected to be related to higher pain intensity, more opioid use, and poorer opioid weaning after surgery. Methods A total of 239 patients reported smoking status in their presurgical assessment (62 smokers, 92 past smokers, and 85 never smokers). Pain and daily opioid use were assessed in hospital before postsurgical discharge, at first outpatient visit (median of 1 month postsurgery), and at last outpatient visit (median of 3 months postsurgery). Pain was measured using numeric rating scale. Morphine equivalent daily opioid doses were calculated for each patient. Results Current smokers reported significantly higher pain intensity (p < .05) at 1 month postsurgery than never smokers and past smokers. Decline in opioid consumption differed significantly by smoking status, with both current and past smokers reporting a less than expected decline in daily opioid consumption (p < .05) at 3 months. Decline in opioid consumption was also related to pack-years, with those reporting higher pack-years having a less than expected decline in daily opioid consumption at 3 months (p < .05). Conclusions Smoking status may be an important modifiable risk factor for pain intensity and opioid use after surgery. Implications In a population with complex postsurgical pain, smoking was associated with greater pain intensity at 1 month after major surgery and less opioid weaning 3 months after surgery. Smoking may be an important modifiable risk factor for pain intensity and opioid use after surgery.

IP005. Preoperative Aneurysmal Thrombus Volume and Patency of Aortic Branch Vessels Are Inversely Correlated in Abdominal Aortic Aneurysm

population. AD mortality trends were evaluated within sex and race strata and compared with aortic aneurysm mortality using linear regression. Differences in county-specific mortality rates were assessed using the Kruskal-Wallis test. Results: Of the 1,014,039 total deaths that occurred during the study period, 2048 were AD related (60% male, 88% white). In 82% of the cases, AD was noted as the underlying COD (Table). The mean AD-related mortality rate was 1.7 6 0.3 deaths/100,000 compared with 6.3 6 1.7 deaths/ 100,000, the aortic aneurysm-related mortality. There was no change in AD-related mortality over time in comparison to a decline in aortic aneurysm-related mortality during the same period (P < .001; Fig). In ADrelated deaths, the mean age at death was 67.8 6 16.0 years and remained stable over time. Whereas there were no differences in ADrelated mortality rates by sex (P 1⁄4 .9), there was a significant increase in mortality rate among individuals who are nonwhite compared with white (an increase of 0.04 vs 0.0006 death/100,000/year, respectively; P 1⁄4 .01). Mortality rates varied significantly across counties (range, 0.02145.9 deaths/100,000; P < .001), and there was no obvious pattern to this variation. An autopsy was completed in 640 (32%) cases, of which 92% reported AD as underlying COD. Among those, 50.2% had an associated COD of aortic rupture. A higher percentage of hypertensive heart disease was noted among those with rupture (70% vs 47%; P < .001). Conclusions: AD-related mortality did not decline in 21 years in Washington state in contrast to a significant drop in aortic aneurysm-related mortality during the same period. Significant racial and geographic variations were noted. These observations are a first step toward regional population assessments that could potentially change care patterns at the state level.

IP041. Acute and Chronic Renal Dysfunction After Open and Endovascular Abdominal Aortic Aneurysm Repair

configurations include 2 with one fenestration, 18 with two fenestrations, 2 with three fenestrations, 5 with a scallop and one fenestration, and 73 with a scallop and two fenestrations. Mean operative time was 224.4 6 72.1 minutes with a blood loss of 508.2 6 561.0 mL. Mean fluoroscopy time was 64.8 6 25.9 minutes with a radiation dose of 966.5 6 652.6 Gy/cm and 116.3 6 41.4 mL iodinated contrast material. There was no difference in operative time, blood loss, or mean fluoroscopy time between the first 50 and last 50 cases. Mean contrast material volume decreased by 14% from 125 mL to 107 mL (P 1⁄4 .02). The 30-day morbidity includes myocardial infarction (2%), arrhythmia (3%), reintubation (2%), gastrointestinal ischemia (3%), and stroke (1%). There were three perioperative deaths due to decompensated cirrhosis, mesenteric ischemia, and cardiopulmonary arrest, respectively. At an average follow-up of 1.0 6 1.0 years, there were no aneurysm-related deaths with four branch stent thromboses (99% patency) and 91% freedom from endoleak. Reintervention was required in 18 patients, most often for branch vessel kinking (4), endoleak (4), mesenteric ischemia (3), access-related complications (3), and stent maldeployment or thrombosis (2). Conclusions: Despite the complexity and associated risks of FEVAR, outcomes at a high-volume center demonstrate acceptable morbidity and freedom from branch occlusion and endoleaks.

Long-term results of thigh arteriovenous dialysis grafts:

Introduction: A proportion of hemodialysis patients exhaust all options for arteriovenous access in upper extremities. Arteriovenous thigh grafts are a potential vascular access option in such patients. Methods: We performed a retrospective study of all thigh arteriovenous access grafts placed between 1995 and 2015. The clinical, demographic patient information and patency of each thigh graft was determined from the time of surgical creation placement until abandonment, transfer to other modality, or center or end of study, and the reason for access failure documented. Results: In total, 44 patients received 49 thigh arteriovenous accesses. The average age was 60 years (13–79 years); Half (53%) of the patients (n = 24) were female and 61% of the patients (n = 30) of arteriovenous accesses were left-sided. The cumulative proportion surviving (primary patency rates) at 12, 24, and 28 months were 43% (standard error = 9%), 33% (standard error = 9%), and 13% (standard error = 9%), respectively. The cumulative proportion of surviving grafts at 12, 24, and 48 months were 61% (standard error = 8%), 58% (standard error = 9%), and 31% (standard error = 13%), respectively. In total, 37 revisions were performed in 22 patients to maintain patency or eradicate infection. Infection occurred in 20 patients (39%) of thigh grafts requiring 16 patients (80% of those affected) to be removed; 14 patients had grafts (33.3%) that served as the lone hemodialysis arteriovenous access during the patients’ lifetime on dialysis. Conclusion: Arteriovenous thigh graft access is used infrequently, but they have an acceptable patency. Some accesses require revisions and they have a high infection rate. Despite this, an acceptable proportion of leg grafts provide durable access for the dialysis lifetime of the patient.

Opioid weaning and pain management in postsurgical patients at the Toronto General Hospital Transitional Pain Service

ABSTRACT Background: The perioperative period provides a critical window to address opioid use, particularly in patients with a history of chronic pain and presurgical opioid use. The Toronto General Hospital Transitional Pain Service (TPS) was developed to address the issues of pain and opioid use after surgery. Aims: To provide program evaluation results from the TPS at the Toronto General Hospital highlighting opioid weaning rates and pain management of opioid-naïve and opioid-experienced surgical patients. Methods: Two hundred fifty-one high-risk TPS patients were dichotomized preoperatively as opioid naïve or opioid experienced. Outcomes included pain, opioid consumption, weaning rates, and psychosocial/medical comorbidities. Results: Six months postoperatively, pain and function were significantly improved. Opioid-naïve and opioid-experienced patients reduced consumption by 69% and 44%, respectively. Forty-six percent and 26% weaned completely. Consumption at hospital discharge predicted weaning in opioid-naïve patients. Pain catastrophizing, neuropathy, and recreational drug use predicted weaning in opioid-experienced patients. Conclusions: The TPS enabled almost half of opioid-naïve patients and one in four opioid-experienced patients to wean. The TPS successfully targets perioperative opioid use in complex pain patients.

Endovascular Repair of Abdominal Aortic Aneurysm in Octogenarians: A Report on Clinical Outcomes

normal three-vessel runoff. Synthetic (polytetrafluoroethylene) grafts were more commonly used as conduit (62.5%) than harvested veins. The average postoperative hospital stay was 4.2 days, with 19% having early postoperative complications (wound infection or dehiscence). Regarding long-term complications (>30 days), only 7.2% of patients suffered minor transient nerve injury, whereas 4.7% of patients had persistent wound infections. The 5-year primary patency was 83.3% overall and 91.8% in elective cases. Conclusions: Open repair of popliteal artery aneurysms through a posterior approach represents an excellent option, with few complications and good long-term primary patency, especially in elective patients.