Objective: A randomized controlled trial was conducted to evaluate the effect of a postdischarge ... more Objective: A randomized controlled trial was conducted to evaluate the effect of a postdischarge app on 30-day readmissions and patient-reported outcomes following colorectal surgery. Background: Patients undergoing colorectal surgery are particularly vulnerable during their transition from hospital-to-home. There has been increasing interest in e-health to provide cost-effective transitional care. An integrated discharge monitoring program using a mobile app platform was developed to support patients after surgery. Methods: A 2 arm, superiority randomized control trial was conducted at an academic tertiary care center with patients undergoing elective colorectal surgery. The intervention group received usual postoperative care and postdischarge monitoring with the app. The primary outcome was 30-day readmissions following hospital discharge. Results: Two hundred eighty-two participants were randomized. The majority were young, had inflammatory bowel disease and underwent laparoscopic surgery. Intention to treat analysis showed no difference between groups for 30-day readmission (14.8% vs 17.6%, P=0.55), ER visits (25.0% vs 28.8%, P=0.49), primary care visits (12.5% vs 8.8%, P=0.34) or unplanned healthcare visits (34.4% vs 35.2%, P=0.89). All patient reported outcomes were significantly improved with median scores higher with the app for satisfaction [9, interquartile range (IQR): 8–10 vs 8, IQR: 7–9, P=0.001], well-being (7, IQR: 6–8 vs 6, IQR: 5–7, P=0.001) and significantly lower for anxiety (3, IQR: 2–5 vs 5, IQR: 3–6, P=0.001). Conclusions: Although the app did not show a significant reduction in 30-day readmission or ER visits, it did lead to significant improvements in patient-reported outcomes. The app may be an important tool to support patients following colorectal surgery.
On behalf of the Canadian Partnership Against Cancer (Partnership), thank you for your submission... more On behalf of the Canadian Partnership Against Cancer (Partnership), thank you for your submission in response to the above RFP. Following a competitive application process, all proposals were adjudicated by a panel consisting of external experts to ensure alignment with the objectives of the Accelerated Diffusion of Strategic Quality Initiatives for Diagnosis and Treatment of Cancer. Following this thorough review, we are pleased to inform you that your proposal was selected for funding. Feedback from the review panel addressed certain recommendations which will be an important first step in negotiating the funding agreement. Copies of the evaluation panel reports are attached. The feedback and next steps will be discussed in a meeting to be scheduled in the near future. Thank you for your support and commitment to advancing Quality Initiatives for Diagnosis and Treatment of Cancer. We look forward to working with you.
Background: Operative reports (ORs) serve as the official documentation of surgical procedures. T... more Background: Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. Methods: A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. Results: We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repairspecific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%). Conclusion: Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR. Contexte : Les notes opératoires (NO) servent à documenter officiellement les interventions chirurgicales. Elles sont indispensables à des soins optimaux aux patients, à l'imputabilité des médecins, à la facturation de leurs actes, à l'orientation de la recherche clinique et aux vérifications. Les notes narratives non standardisées sont souvent de piètre qualité et incomplètes. Nous avons voulu vérifier l'exhaustivité des notes opératoires narratives concernant les réparations d'hernies inguinales (RHI). Méthodes : Une équipe de 4 chirurgiens a créé une liste de vérification standardisée consensuelle comprenant 33 variables applicables à la RHI. Cinq chirurgiens experts des RHI ont classé ces éléments selon qu'ils leurs semblaient essentiels, préférables ou non essentiels. Nous avons passé en revue les NO des RHI ouvertes effectuées dans 6 hôpitaux universitaires. Résultats : Nous avons passé en revue 213 NO et nous avons exclus les NO concernant 7 hernies fémorales. Les réparations sans tension se sont révélées les plus communes (82,5 %) et la technique plug-and-patch a été la plus fréquente (52,9 %). Les résidents ont dicté 59 % des NO. Sur les 33 variables, 15 étaient considérées essentielles et en moyenne, 10,8 ± 1,3 ont été incluses dans les NO. Parmi les éléments qui laissaient à désirer, mentionnons : première réparation c. réparation récurrente (8,3 %), viabilité du grêle dans les hernies incarcérées (10,7 %) et complications peropératoires (32,5 %). Parmi les 18 éléments jugés non essentiels, la prophylaxie contre la thrombose veineuse profonde, l'antibioprophylaxie et le degré d'urgence ont été mentionnés dans 1,9 %, 11,7 % et 24,3 % des NO, respectivement. Les détails spécifiques à la réparation ont été notés dans 0 à 97,1 % des NO, y compris la fixation de la prothèse au tubercule par des sutures (55,1 %) et la localisation du bouchon (67,0 %). Conclusion : L'exhaustivité des NO consignées dans les cas de RHI a varié en ce qui a trait aux éléments jugés essentiels et non essentiels et les NO se sont généralement révélées incomplètes. On en conclut qu'il y a place à amélioration, entre autre par l'adoption d'un modèle synoptique standardisé de NO.
BACKGROUND: Following IPAA failure, select patients are eligible for IPAA revision. Presently, th... more BACKGROUND: Following IPAA failure, select patients are eligible for IPAA revision. Presently, there is limited evidence describing long-term revision outcomes and predictors of revision failure. This represents an important knowledge gap when selecting and counseling patients. OBJECTIVE: This study aimed to define long-term IPAA survival outcomes after transabdominal IPAA revision and identify preoperative clinical factors associated with revision failure. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: This study included all patients who underwent revisional IPAA surgery between 1982 and 2017 for pouch failure. INTERVENTION: Transabdominal IPAA revision was included. MAIN OUTCOME MEASURES: The primary outcome was pouch failure, defined as pouch excision or permanent pouch diversion, after IPAA revision. RESULTS: A total of 159 patients (64.2% women) were included with a median age of 36 years (interquartile range, 28.5–46.5) at revision. Eighty percent of patients had a primary diagnosis of ulcerative colitis. The most common indication for revision was leak/pelvic sepsis, representing 41% of the cohort, followed by pouch-vaginal fistula (22.2%), mechanical factors (20.4%), and poor pouch function (14.6%). During the study period, 56 patients (35.2%) experienced pouch failure. The 3-year pouch survival probability was 82.3% (95% CI, 75.5%–87.5%), 5-year pouch survival probability was 77.2% (95% CI, 69.8%–83.0%), and 10-year pouch survival probability was 70.6% (95% CI, 62.6%–77.2%). Compared to mechanical factors, pouch failure was significantly associated with pelvic sepsis (HR, 4.25; 95% CI, 1.50–12.0) and pouch-vaginal fistula (HR, 4.37; 95% CI, 1.47–12.99). No significant association was found between revision failure and previous revision, redo ileoanal anastomosis, or new pouch construction. LIMITATIONS: This study is limited by its retrospective design. CONCLUSIONS: Revisional IPAA can be undertaken with favorable long-term outcomes at high-volume centers. Consideration should be given to indication for revision when counseling patients regarding the risk of failure. Further research on risk stratifying patients before revision is required. See Video at http://links.lww.com/DCR/B966. REVISIÓN DE LA ANASTOMOSIS ANAL DE LA BOLSA ILEAL TRANSABDOMINAL: ¿LA INDICACIÓN DICTA EL RESULTADO? ANTECEDENTES: Después de la falla en la anastomosis del reservorio ileoanal, los pacientes seleccionados son elegibles para la revisión de la anastomosis del reservorio ileoanal. Actualmente, hay evidencias limitadas que describen los resultados de la revisión a largo plazo y los predictores del fracaso de la revisión. Esto representa un importante vacío de investigación a la hora de seleccionar y asesorar a los pacientes. OBJETIVO: Definir los resultados de supervivencia a largo plazo de la IPAA después de la revisión de la anastomosis del reservorio ileoanal transabdominal e identificar los factores clínicos preoperatorios asociados con el fracaso de la revisión. DISEÑO: Este fue un estudio de cohorte retrospectivo. ENTORNO CLINICO: Este estudio se realizó en un centro de referencia terciario. PARTICIPANTES: Todos los pacientes que se sometieron a una cirugía de revisión de la anastomosis ileoanal del reservorio entre 1982 y 2017, por falla del reservorio. INTERVENCIÓN: Revisión de la anastomosis de reservorio ileoanal transabdominal. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario es el fracaso del reservorio, definido como escisión del reservorio o derivación permanente del reservorio, después de la revisión de la anastomosis del reservorio ileoanal. RESULTADOS: Se incluyeron un total de 159 pacientes (64,2% mujeres) con una mediana de edad a la revisión de 36 años (RIC: 28,5-46,5). El ochenta por ciento tenía un diagnóstico primario de colitis ulcerosa. La indicación más común para la revisión fue la fuga/sepsis pélvica, que representó el 41 % de la cohorte, seguida de la fístula vaginal del reservorio (22,2 %), factores mecánicos (20,4 %) y mala función del reservorio 14,6 %. Durante el período de estudio, 56 pacientes (35,2 %) experimentaron fallas en la bolsa. Las probabilidades de supervivencia de la bolsa a los 3, 5 y 10 años fueron del 82,3% (IC del 95%: 75,5%-87,5%), del 77,2% (IC del 95%: 69,8%-83,0%) y del 70,6% (IC del 95%: 62,6%- 77,2%), respectivamente. En comparación con los factores mecánicos, la falla de la bolsa se asoció significativamente con sepsis pélvica (HR = 4,25, IC del 95 %: 1,50 a 12,0) y fístula vaginal de la bolsa (HR = 4,37, IC del 95 %: 1,47 a 12,99). No hubo una asociación significativa entre el fracaso de la revisión y la revisión previa, el rehacer la anastomosis ileoanal o la construcción de una nueva bolsa. LIMITACIONES: El estudio está limitado por su diseño retrospectivo. CONCLUSIONES: La revisión de la anastomosis del reservorio ileoanal se puede realizar con resultados favorables a largo plazo…
BACKGROUND: Although the accuracy of preoperative MRI staging has been established on follow-up h... more BACKGROUND: Although the accuracy of preoperative MRI staging has been established on follow-up histopathologic examination, the reproducibility of MRI staging has been evaluated in studies with expert radiologists reading a large sample of MRI images and therefore is not generalizable to the real-world setting. OBJECTIVE: The purpose of this study was to evaluate the interrater reliability of MRI for distance to the mesorectal fascia, T category, mesorectal lymph node status, and extramural depth of invasion for preoperative staging of primary rectal cancer. DESIGN: This was a prospective, cross-sectional survey. SETTINGS: The study was conducted in Ontario, Canada. PARTICIPANTS: Participants included GI radiologists. INTERVENTIONS: Participants read 5 preselected staging MRIs using a synoptic report and participated in an educational Webinar. MAIN OUTCOME MEASURES: Distance to the mesorectal fascia, T category, extramural depth of invasion, and mesorectal lymph node status for each MRI were abstracted. Data were analyzed in aggregate using percentage of agreement, Fleiss κ, and interclass correlation coefficients to assess interrater reliability. RESULTS: Reliability was highest for distance to the mesorectal fascia with an intraclass correlation of 0.58 (95% CI, 0.27–0.80). Kappa scores for T category, mesorectal lymph node status, and extramural depth of invasion were 0.38 (95% CI, 0.23–0.46), 0.41 (95% CI, 0.32–0.49), and 0.37 (95% CI, 0.16–0.82). There was no difference when radiologists were stratified by experience or volume. LIMITATIONS: Scores may have been affected by MRI selection, because they were chosen to demonstrate diagnostic challenges for the Webinar and did not reflect a representative sample. CONCLUSIONS: Interrater reliability was highest for distance to mesorectal fascia, and therefore, it may be a more reliable criterion than T category, extramural depth of invasion, or mesorectal lymph node status. Combined with the fact that an uninvolved mesorectal fascia is more consistent with the overall goal of rectal cancer surgery, it should be considered as an important MRI criterion for preoperative treatment decision making in the real-world setting. See Video at http://links.lww.com/DCR/A763.
tients (15.3%) died, and 2,442 (48%) experienced at least 1 morbidity. Median differences in hosp... more tients (15.3%) died, and 2,442 (48%) experienced at least 1 morbidity. Median differences in hospital rank between nonemergency and emergency performance were 35 for mortality and 30 for morbidity. No structural characteristics (bed size, accreditation, teaching status, trauma center level, or rural/urban location) were associated with improved outcomes for emergency surgery morbidity or mortality. Additionally, linear regression revealed that no structural characteristics were associated with differences in mortality or morbidity outcomes when comparing individual hospital nonemergency and emergency surgery performance. CONCLUSIONS: Hospitals with favorable elective surgery outcomes do not necessarily have similar outcomes for emergency cases. Hospitals should examine their performance on emergency surgical procedures and focus quality improvement efforts appropriately.
Canadian journal of surgery. Journal canadien de chirurgie
Operative reports (ORs) serve as the official documentation of surgical procedures. They are esse... more Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent...
Background: Diabetes is an increasingly prevalent chronic disease. Many of these patients may dev... more Background: Diabetes is an increasingly prevalent chronic disease. Many of these patients may develop breast cancer (BC). A meta-analysis by Larsson (2007)demonstrated that diabetic women have an increased risk (RR: 1.2) of BC particularly for estrogen receptor positive (ER+) subtypes (RR: 1.22). However, a recent study by Bodmer (2010) showed that women on long-term metformin have a reduced incidence of BC (OR 0.44, 95% CI 0.24-0.82). Metformin has antiproliferative effects on BC based on studies using proliferative marker Ki67. BC patients on metformin have better cancer-specific survival based on Landman (2010). We hypothesize that when compared to other diabetic medications; including exogenous insulin and other oral hypoglycemics; metformin specifically reduces the incidence of triple negative BCs (TNBC or ER-/PR-/Her2-). Methods: We conducted a retrospective chart review of an unselected cohort of patients who underwent surgical interventions for their primary BC to correlate ...
BACKGROUND: Few studies have reported surgical outcomes following pouch excision and fewer have d... more BACKGROUND: Few studies have reported surgical outcomes following pouch excision and fewer have described the long-term sequelae. Given the debate regarding optimal surgical management following pouch failure, an accurate estimation of the morbidity associated with this procedure addresses a critical knowledge gap. OBJECTIVE: The objective of this study was to review our institutional experience with pouch excision with a focus on indications, short-term outcomes, and long-term reintervention rates. DESIGN: This was a retrospective cohort study. SETTING: This study was conducted at Mount Sinai Hospital, Toronto, Ontario Canada. PARTICIPANTS: Adult patients registered in the prospectively maintained IBD database with a diagnosis of pelvic pouch failure between 1991 and 2018 were selected. INTERVENTION: The patients had undergone pelvic pouch excision was measured. MAIN OUTCOMES AND MEASURES: Indications for excision, incidence of short-term and long-term complications, and long-term surgical reintervention were the primary outcomes. In addition, multivariable logistic regression models were fitted to identify predictors of chronic perineal wound complications and the effect of preoperative diversion. The positive predictive value of a clinical suspicion of Crohn’s disease of the pouch was also evaluated. RESULTS: One hundred forty cases were identified. Fifty-nine percent of patients experienced short-term complications and 49.3% experienced delayed morbidity. Overall, one-third of patients required long-term reoperation related to perineal wound, stoma, and hernia complications. On multivariable regression, immunosuppression was associated with increased odds of perineal wound complications, and preoperative diversion was not associated with perineal wound healing. Crohn’s disease was suspected in 24 patients preoperatively but confirmed on histopathology in only 6 patients. LIMITATIONS: This is a retrospective chart review of a single institution’s experience, whereby complication rates may be underestimates of the true event rates. CONCLUSIONS: Pouch excision is associated with high postoperative morbidity and long-term reintervention due to nonhealing perineal wounds, stoma complications, and hernias. Further study is required to clarify risk reduction strategies to limit perineal wound complications and the appropriate selection of patients for diversion alone vs pouch excision in IPAA failure. See Video Abstract at http://links.lww.com/DCR/B348. RESULTADOS A CORTO Y LARGO PLAZO DESPUÉS DE LA EXTIRPACIÓN DE LA BOLSA PéLVICA: LA EXPERIENCIA DEL HOSPITAL MOUNT SINAÍ ANTECEDENTES: Pocos estudios han informado resultados quirúrgicos después de la escisión de bolsa pélvica (reservorio ileoanal) y menos han descrito las secuelas a largo plazo. Dado el debate sobre el manejo quirúrgico óptimo después de la falla de la bolsa, una estimación precisa de la morbilidad asociada con este procedimiento aborda una brecha crítica de conocimiento. OBJETIVO: El objetivo de este estudio fue revisar nuestra experiencia institucional con la extirpación de la bolsa con un enfoque en las indicaciones, los resultados a corto plazo y las tasas de reintervención a largo plazo. DISEÑO: Estudio de cohorte retrospectivo. ENTORNO CLINICO: Hospital Mt Sinaí, Toronto, Ontario, Canadá. PARTICIPANTES: Pacientes adultos registrados en la base de datos de EII mantenida prospectivamente con un diagnóstico de falla de la bolsa pélvica entre 1991 y 2018. INTERVENCIÓN: Escisión de bolsa pélvica. PRINCIPALES RESULTADOS Y MEDIDAS: Las indicaciones para la escisión, la incidencia de complicaciones a corto y largo plazo y la reintervención quirúrgica a largo plazo fueron los resultados primarios valorados. Además, se ajustaron modelos de regresión logística multivariable para identificar predictores de complicaciones de la herida perineal crónica y el efecto de la derivación preoperatoria. También se evaluó el valor predictivo positivo de una sospecha clínica de enfermedad de Crohn de la bolsa. RESULTADOS: Se identificaron 140 casos. El 59% de los pacientes desarrollaron complicaciones a corto plazo y el 49,3% con morbilidad tardía. En general, 1/3 de los pacientes requirieron una reoperación a largo plazo relacionada con complicaciones de herida perineal, estoma y hernia. En la regresión multivariable, la inmunosupresión se asoció con mayores probabilidades de complicaciones de la herida perineal y la derivación preoperatoria no se asoció con la cicatrización de la herida perineal. La enfermedad de Crohn se sospechó en 24 pacientes antes de la operación, pero se confirmó por histopatología en solo 6 pacientes. LIMITACIONES: Revisión retrospectiva del cuadro de la experiencia de una sola institución por la cual las tasas de complicaciones pueden ser subestimadas de las tasas de eventos reales. CONCLUSIONES: La escisión de la bolsa se asocia con una alta morbilidad postoperatoria y una reintervención a largo plazo debido a complicaciones de…
It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer confere... more It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer conference (MCCs), (iii) preoperative radiotherapy, (iv) total mesorectal excision surgery and (v) pathological assessment as described by Quirke are key processes necessary for high quality, rectal cancer care. The objective was to select a set of multidisciplinary quality indicators to measure the uptake of these clinical processes in clinical practice.
Background Patient engagement is the establishment of active partnerships between patients, famil... more Background Patient engagement is the establishment of active partnerships between patients, families, and health professionals to improve healthcare delivery. The objective of this project was to conduct a series of patient engagement workshops to identify areas to improve the surgical experience and develop strategies to address areas identified as high priority. Methods Faculty surgeons and patients were invited to participate in three in-person meetings. Evaluation included identifying and developing strategies for three priority areas to improve the surgical experience and level of engagement achieved at each meeting. Results Sixteen faculty surgeons and 32 patients participated. Some 63 themes to improve the surgical experience were identified; the three highest-priority themes were physician communication, discharge process, and expectations at home after discharge. Individual improvement strategies for these three prioritized themes (12, 36 and 6 respectively) were used to de...
Background Over the last 2 decades, the use of multimodal strategies, including total mesorectal ... more Background Over the last 2 decades, the use of multimodal strategies, including total mesorectal excision (TME) surgery, preoperative chemotherapy, multidisciplinary case conference, pelvic magnetic resonance imaging, and pathologic assessment using Quirke method, has led to significant improvements in oncologic outcomes for patients with rectal cancer. Although the literature supports claims on the effectiveness of these multimodal strategies, the uptake of these multimodal strategies varies considerably among centers, suggesting that the best evidence is not always implemented into clinical practice. Objective This study aims to perform a quality improvement initiative to (1) identify existing gaps in care for these multimodal strategies and (2) implement knowledge translation (KT) interventions to close these gaps to optimize quality of care for patients with rectal cancer across high-volume centers in Canada. Methods Process indicators for the selected multimodal strategies to o...
IMPORTANCE Chemoradiotherapy (CRT), followed by surgery, is the recommended approach for stage II... more IMPORTANCE Chemoradiotherapy (CRT), followed by surgery, is the recommended approach for stage II and III rectal cancer. While CRT decreases the risk of local recurrence, it does not improve survival and leads to poorer functional outcomes than surgery alone. Therefore, new approaches to better select patients for CRT are important. OBJECTIVE To conduct a phase 2 study to evaluate the safety and feasibility of using magnetic resonance imaging (MRI) criteria to select patients with "good prognosis" rectal tumors for primary surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective nonrandomized phase 2 study at 12 high-volume colorectal surgery centers across Canada. From September 30, 2014, to October 21, 2016, a total of 82 patients were recruited for the study. Participants were patients newly diagnosed as having rectal cancer with MRI-predicted good prognosis rectal cancer. The MRI criteria for good prognosis tumors included distance to the mesorectal fascia greater than 1 mm; definite T2, T2/early T3, or definite T3 with less than 5 mm of extramural depth of invasion; and absent or equivocal extramural venous invasion. INTERVENTIONS Patients with rectal cancer with MRI-predicted good prognosis tumors underwent primary surgery. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients with a positive circumferential resection margin (CRM) rate. Assuming a 10% baseline probability of a positive CRM, a sample size of 75 was estimated to yield a 95% CI of ±6.7%. RESULTS Eighty-two patients (74% male) participated in the study. The median age at the time of surgery was 66 years (range, 37-89 years). Based on MRI, most tumors were midrectal (65% [n = 53]), T2/early T3 (60% [n = 49]), with no suspicious lymph nodes (63% [n = 52]). On final pathology, 91% (n = 75) of tumors were T2 or greater, 29% (n = 24) were node positive, and 59% (n = 48) were stage II or III. The positive CRM rate was 4 of 82 (4.9%; 95% CI, 0.2%-9.6%). CONCLUSIONS AND RELEVANCE The use of MRI criteria to select patients with good prognosis rectal cancer for primary surgery results in a low rate of positive CRM and suggests that CRT may not be necessary for all patients with stage II and III rectal cancer.
Canadian journal of surgery. Journal canadien de chirurgie, 2013
Operative reports (ORs) serve as the official documentation of surgical procedures. They are esse... more Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent...
Objective: A randomized controlled trial was conducted to evaluate the effect of a postdischarge ... more Objective: A randomized controlled trial was conducted to evaluate the effect of a postdischarge app on 30-day readmissions and patient-reported outcomes following colorectal surgery. Background: Patients undergoing colorectal surgery are particularly vulnerable during their transition from hospital-to-home. There has been increasing interest in e-health to provide cost-effective transitional care. An integrated discharge monitoring program using a mobile app platform was developed to support patients after surgery. Methods: A 2 arm, superiority randomized control trial was conducted at an academic tertiary care center with patients undergoing elective colorectal surgery. The intervention group received usual postoperative care and postdischarge monitoring with the app. The primary outcome was 30-day readmissions following hospital discharge. Results: Two hundred eighty-two participants were randomized. The majority were young, had inflammatory bowel disease and underwent laparoscopic surgery. Intention to treat analysis showed no difference between groups for 30-day readmission (14.8% vs 17.6%, P=0.55), ER visits (25.0% vs 28.8%, P=0.49), primary care visits (12.5% vs 8.8%, P=0.34) or unplanned healthcare visits (34.4% vs 35.2%, P=0.89). All patient reported outcomes were significantly improved with median scores higher with the app for satisfaction [9, interquartile range (IQR): 8–10 vs 8, IQR: 7–9, P=0.001], well-being (7, IQR: 6–8 vs 6, IQR: 5–7, P=0.001) and significantly lower for anxiety (3, IQR: 2–5 vs 5, IQR: 3–6, P=0.001). Conclusions: Although the app did not show a significant reduction in 30-day readmission or ER visits, it did lead to significant improvements in patient-reported outcomes. The app may be an important tool to support patients following colorectal surgery.
On behalf of the Canadian Partnership Against Cancer (Partnership), thank you for your submission... more On behalf of the Canadian Partnership Against Cancer (Partnership), thank you for your submission in response to the above RFP. Following a competitive application process, all proposals were adjudicated by a panel consisting of external experts to ensure alignment with the objectives of the Accelerated Diffusion of Strategic Quality Initiatives for Diagnosis and Treatment of Cancer. Following this thorough review, we are pleased to inform you that your proposal was selected for funding. Feedback from the review panel addressed certain recommendations which will be an important first step in negotiating the funding agreement. Copies of the evaluation panel reports are attached. The feedback and next steps will be discussed in a meeting to be scheduled in the near future. Thank you for your support and commitment to advancing Quality Initiatives for Diagnosis and Treatment of Cancer. We look forward to working with you.
Background: Operative reports (ORs) serve as the official documentation of surgical procedures. T... more Background: Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. Methods: A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. Results: We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent repair (8.3%), small bowel viability in incarcerated hernias (10.7%) and occurrence of intraoperative complications (32.5%). Of 18 nonessential elements, deep vein thrombosis prophylaxis, preoperative antibiotics and urgency were reported in 1.9%, 11.7% and 24.3% of ORs, respectively. Repairspecific details were reported in 0 to 97.1% of ORs, including patch sutured to tubercle (55.1%) and location of plug (67.0%). Conclusion: Completeness of IHR ORs varied with regards to essential and nonessential items but were generally incomplete, suggesting there is opportunity for improvement, including implementation of a standardized synoptic OR. Contexte : Les notes opératoires (NO) servent à documenter officiellement les interventions chirurgicales. Elles sont indispensables à des soins optimaux aux patients, à l'imputabilité des médecins, à la facturation de leurs actes, à l'orientation de la recherche clinique et aux vérifications. Les notes narratives non standardisées sont souvent de piètre qualité et incomplètes. Nous avons voulu vérifier l'exhaustivité des notes opératoires narratives concernant les réparations d'hernies inguinales (RHI). Méthodes : Une équipe de 4 chirurgiens a créé une liste de vérification standardisée consensuelle comprenant 33 variables applicables à la RHI. Cinq chirurgiens experts des RHI ont classé ces éléments selon qu'ils leurs semblaient essentiels, préférables ou non essentiels. Nous avons passé en revue les NO des RHI ouvertes effectuées dans 6 hôpitaux universitaires. Résultats : Nous avons passé en revue 213 NO et nous avons exclus les NO concernant 7 hernies fémorales. Les réparations sans tension se sont révélées les plus communes (82,5 %) et la technique plug-and-patch a été la plus fréquente (52,9 %). Les résidents ont dicté 59 % des NO. Sur les 33 variables, 15 étaient considérées essentielles et en moyenne, 10,8 ± 1,3 ont été incluses dans les NO. Parmi les éléments qui laissaient à désirer, mentionnons : première réparation c. réparation récurrente (8,3 %), viabilité du grêle dans les hernies incarcérées (10,7 %) et complications peropératoires (32,5 %). Parmi les 18 éléments jugés non essentiels, la prophylaxie contre la thrombose veineuse profonde, l'antibioprophylaxie et le degré d'urgence ont été mentionnés dans 1,9 %, 11,7 % et 24,3 % des NO, respectivement. Les détails spécifiques à la réparation ont été notés dans 0 à 97,1 % des NO, y compris la fixation de la prothèse au tubercule par des sutures (55,1 %) et la localisation du bouchon (67,0 %). Conclusion : L'exhaustivité des NO consignées dans les cas de RHI a varié en ce qui a trait aux éléments jugés essentiels et non essentiels et les NO se sont généralement révélées incomplètes. On en conclut qu'il y a place à amélioration, entre autre par l'adoption d'un modèle synoptique standardisé de NO.
BACKGROUND: Following IPAA failure, select patients are eligible for IPAA revision. Presently, th... more BACKGROUND: Following IPAA failure, select patients are eligible for IPAA revision. Presently, there is limited evidence describing long-term revision outcomes and predictors of revision failure. This represents an important knowledge gap when selecting and counseling patients. OBJECTIVE: This study aimed to define long-term IPAA survival outcomes after transabdominal IPAA revision and identify preoperative clinical factors associated with revision failure. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a tertiary referral center. PATIENTS: This study included all patients who underwent revisional IPAA surgery between 1982 and 2017 for pouch failure. INTERVENTION: Transabdominal IPAA revision was included. MAIN OUTCOME MEASURES: The primary outcome was pouch failure, defined as pouch excision or permanent pouch diversion, after IPAA revision. RESULTS: A total of 159 patients (64.2% women) were included with a median age of 36 years (interquartile range, 28.5–46.5) at revision. Eighty percent of patients had a primary diagnosis of ulcerative colitis. The most common indication for revision was leak/pelvic sepsis, representing 41% of the cohort, followed by pouch-vaginal fistula (22.2%), mechanical factors (20.4%), and poor pouch function (14.6%). During the study period, 56 patients (35.2%) experienced pouch failure. The 3-year pouch survival probability was 82.3% (95% CI, 75.5%–87.5%), 5-year pouch survival probability was 77.2% (95% CI, 69.8%–83.0%), and 10-year pouch survival probability was 70.6% (95% CI, 62.6%–77.2%). Compared to mechanical factors, pouch failure was significantly associated with pelvic sepsis (HR, 4.25; 95% CI, 1.50–12.0) and pouch-vaginal fistula (HR, 4.37; 95% CI, 1.47–12.99). No significant association was found between revision failure and previous revision, redo ileoanal anastomosis, or new pouch construction. LIMITATIONS: This study is limited by its retrospective design. CONCLUSIONS: Revisional IPAA can be undertaken with favorable long-term outcomes at high-volume centers. Consideration should be given to indication for revision when counseling patients regarding the risk of failure. Further research on risk stratifying patients before revision is required. See Video at http://links.lww.com/DCR/B966. REVISIÓN DE LA ANASTOMOSIS ANAL DE LA BOLSA ILEAL TRANSABDOMINAL: ¿LA INDICACIÓN DICTA EL RESULTADO? ANTECEDENTES: Después de la falla en la anastomosis del reservorio ileoanal, los pacientes seleccionados son elegibles para la revisión de la anastomosis del reservorio ileoanal. Actualmente, hay evidencias limitadas que describen los resultados de la revisión a largo plazo y los predictores del fracaso de la revisión. Esto representa un importante vacío de investigación a la hora de seleccionar y asesorar a los pacientes. OBJETIVO: Definir los resultados de supervivencia a largo plazo de la IPAA después de la revisión de la anastomosis del reservorio ileoanal transabdominal e identificar los factores clínicos preoperatorios asociados con el fracaso de la revisión. DISEÑO: Este fue un estudio de cohorte retrospectivo. ENTORNO CLINICO: Este estudio se realizó en un centro de referencia terciario. PARTICIPANTES: Todos los pacientes que se sometieron a una cirugía de revisión de la anastomosis ileoanal del reservorio entre 1982 y 2017, por falla del reservorio. INTERVENCIÓN: Revisión de la anastomosis de reservorio ileoanal transabdominal. PRINCIPALES MEDIDAS DE RESULTADO: El resultado primario es el fracaso del reservorio, definido como escisión del reservorio o derivación permanente del reservorio, después de la revisión de la anastomosis del reservorio ileoanal. RESULTADOS: Se incluyeron un total de 159 pacientes (64,2% mujeres) con una mediana de edad a la revisión de 36 años (RIC: 28,5-46,5). El ochenta por ciento tenía un diagnóstico primario de colitis ulcerosa. La indicación más común para la revisión fue la fuga/sepsis pélvica, que representó el 41 % de la cohorte, seguida de la fístula vaginal del reservorio (22,2 %), factores mecánicos (20,4 %) y mala función del reservorio 14,6 %. Durante el período de estudio, 56 pacientes (35,2 %) experimentaron fallas en la bolsa. Las probabilidades de supervivencia de la bolsa a los 3, 5 y 10 años fueron del 82,3% (IC del 95%: 75,5%-87,5%), del 77,2% (IC del 95%: 69,8%-83,0%) y del 70,6% (IC del 95%: 62,6%- 77,2%), respectivamente. En comparación con los factores mecánicos, la falla de la bolsa se asoció significativamente con sepsis pélvica (HR = 4,25, IC del 95 %: 1,50 a 12,0) y fístula vaginal de la bolsa (HR = 4,37, IC del 95 %: 1,47 a 12,99). No hubo una asociación significativa entre el fracaso de la revisión y la revisión previa, el rehacer la anastomosis ileoanal o la construcción de una nueva bolsa. LIMITACIONES: El estudio está limitado por su diseño retrospectivo. CONCLUSIONES: La revisión de la anastomosis del reservorio ileoanal se puede realizar con resultados favorables a largo plazo…
BACKGROUND: Although the accuracy of preoperative MRI staging has been established on follow-up h... more BACKGROUND: Although the accuracy of preoperative MRI staging has been established on follow-up histopathologic examination, the reproducibility of MRI staging has been evaluated in studies with expert radiologists reading a large sample of MRI images and therefore is not generalizable to the real-world setting. OBJECTIVE: The purpose of this study was to evaluate the interrater reliability of MRI for distance to the mesorectal fascia, T category, mesorectal lymph node status, and extramural depth of invasion for preoperative staging of primary rectal cancer. DESIGN: This was a prospective, cross-sectional survey. SETTINGS: The study was conducted in Ontario, Canada. PARTICIPANTS: Participants included GI radiologists. INTERVENTIONS: Participants read 5 preselected staging MRIs using a synoptic report and participated in an educational Webinar. MAIN OUTCOME MEASURES: Distance to the mesorectal fascia, T category, extramural depth of invasion, and mesorectal lymph node status for each MRI were abstracted. Data were analyzed in aggregate using percentage of agreement, Fleiss κ, and interclass correlation coefficients to assess interrater reliability. RESULTS: Reliability was highest for distance to the mesorectal fascia with an intraclass correlation of 0.58 (95% CI, 0.27–0.80). Kappa scores for T category, mesorectal lymph node status, and extramural depth of invasion were 0.38 (95% CI, 0.23–0.46), 0.41 (95% CI, 0.32–0.49), and 0.37 (95% CI, 0.16–0.82). There was no difference when radiologists were stratified by experience or volume. LIMITATIONS: Scores may have been affected by MRI selection, because they were chosen to demonstrate diagnostic challenges for the Webinar and did not reflect a representative sample. CONCLUSIONS: Interrater reliability was highest for distance to mesorectal fascia, and therefore, it may be a more reliable criterion than T category, extramural depth of invasion, or mesorectal lymph node status. Combined with the fact that an uninvolved mesorectal fascia is more consistent with the overall goal of rectal cancer surgery, it should be considered as an important MRI criterion for preoperative treatment decision making in the real-world setting. See Video at http://links.lww.com/DCR/A763.
tients (15.3%) died, and 2,442 (48%) experienced at least 1 morbidity. Median differences in hosp... more tients (15.3%) died, and 2,442 (48%) experienced at least 1 morbidity. Median differences in hospital rank between nonemergency and emergency performance were 35 for mortality and 30 for morbidity. No structural characteristics (bed size, accreditation, teaching status, trauma center level, or rural/urban location) were associated with improved outcomes for emergency surgery morbidity or mortality. Additionally, linear regression revealed that no structural characteristics were associated with differences in mortality or morbidity outcomes when comparing individual hospital nonemergency and emergency surgery performance. CONCLUSIONS: Hospitals with favorable elective surgery outcomes do not necessarily have similar outcomes for emergency cases. Hospitals should examine their performance on emergency surgical procedures and focus quality improvement efforts appropriately.
Canadian journal of surgery. Journal canadien de chirurgie
Operative reports (ORs) serve as the official documentation of surgical procedures. They are esse... more Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent...
Background: Diabetes is an increasingly prevalent chronic disease. Many of these patients may dev... more Background: Diabetes is an increasingly prevalent chronic disease. Many of these patients may develop breast cancer (BC). A meta-analysis by Larsson (2007)demonstrated that diabetic women have an increased risk (RR: 1.2) of BC particularly for estrogen receptor positive (ER+) subtypes (RR: 1.22). However, a recent study by Bodmer (2010) showed that women on long-term metformin have a reduced incidence of BC (OR 0.44, 95% CI 0.24-0.82). Metformin has antiproliferative effects on BC based on studies using proliferative marker Ki67. BC patients on metformin have better cancer-specific survival based on Landman (2010). We hypothesize that when compared to other diabetic medications; including exogenous insulin and other oral hypoglycemics; metformin specifically reduces the incidence of triple negative BCs (TNBC or ER-/PR-/Her2-). Methods: We conducted a retrospective chart review of an unselected cohort of patients who underwent surgical interventions for their primary BC to correlate ...
BACKGROUND: Few studies have reported surgical outcomes following pouch excision and fewer have d... more BACKGROUND: Few studies have reported surgical outcomes following pouch excision and fewer have described the long-term sequelae. Given the debate regarding optimal surgical management following pouch failure, an accurate estimation of the morbidity associated with this procedure addresses a critical knowledge gap. OBJECTIVE: The objective of this study was to review our institutional experience with pouch excision with a focus on indications, short-term outcomes, and long-term reintervention rates. DESIGN: This was a retrospective cohort study. SETTING: This study was conducted at Mount Sinai Hospital, Toronto, Ontario Canada. PARTICIPANTS: Adult patients registered in the prospectively maintained IBD database with a diagnosis of pelvic pouch failure between 1991 and 2018 were selected. INTERVENTION: The patients had undergone pelvic pouch excision was measured. MAIN OUTCOMES AND MEASURES: Indications for excision, incidence of short-term and long-term complications, and long-term surgical reintervention were the primary outcomes. In addition, multivariable logistic regression models were fitted to identify predictors of chronic perineal wound complications and the effect of preoperative diversion. The positive predictive value of a clinical suspicion of Crohn’s disease of the pouch was also evaluated. RESULTS: One hundred forty cases were identified. Fifty-nine percent of patients experienced short-term complications and 49.3% experienced delayed morbidity. Overall, one-third of patients required long-term reoperation related to perineal wound, stoma, and hernia complications. On multivariable regression, immunosuppression was associated with increased odds of perineal wound complications, and preoperative diversion was not associated with perineal wound healing. Crohn’s disease was suspected in 24 patients preoperatively but confirmed on histopathology in only 6 patients. LIMITATIONS: This is a retrospective chart review of a single institution’s experience, whereby complication rates may be underestimates of the true event rates. CONCLUSIONS: Pouch excision is associated with high postoperative morbidity and long-term reintervention due to nonhealing perineal wounds, stoma complications, and hernias. Further study is required to clarify risk reduction strategies to limit perineal wound complications and the appropriate selection of patients for diversion alone vs pouch excision in IPAA failure. See Video Abstract at http://links.lww.com/DCR/B348. RESULTADOS A CORTO Y LARGO PLAZO DESPUÉS DE LA EXTIRPACIÓN DE LA BOLSA PéLVICA: LA EXPERIENCIA DEL HOSPITAL MOUNT SINAÍ ANTECEDENTES: Pocos estudios han informado resultados quirúrgicos después de la escisión de bolsa pélvica (reservorio ileoanal) y menos han descrito las secuelas a largo plazo. Dado el debate sobre el manejo quirúrgico óptimo después de la falla de la bolsa, una estimación precisa de la morbilidad asociada con este procedimiento aborda una brecha crítica de conocimiento. OBJETIVO: El objetivo de este estudio fue revisar nuestra experiencia institucional con la extirpación de la bolsa con un enfoque en las indicaciones, los resultados a corto plazo y las tasas de reintervención a largo plazo. DISEÑO: Estudio de cohorte retrospectivo. ENTORNO CLINICO: Hospital Mt Sinaí, Toronto, Ontario, Canadá. PARTICIPANTES: Pacientes adultos registrados en la base de datos de EII mantenida prospectivamente con un diagnóstico de falla de la bolsa pélvica entre 1991 y 2018. INTERVENCIÓN: Escisión de bolsa pélvica. PRINCIPALES RESULTADOS Y MEDIDAS: Las indicaciones para la escisión, la incidencia de complicaciones a corto y largo plazo y la reintervención quirúrgica a largo plazo fueron los resultados primarios valorados. Además, se ajustaron modelos de regresión logística multivariable para identificar predictores de complicaciones de la herida perineal crónica y el efecto de la derivación preoperatoria. También se evaluó el valor predictivo positivo de una sospecha clínica de enfermedad de Crohn de la bolsa. RESULTADOS: Se identificaron 140 casos. El 59% de los pacientes desarrollaron complicaciones a corto plazo y el 49,3% con morbilidad tardía. En general, 1/3 de los pacientes requirieron una reoperación a largo plazo relacionada con complicaciones de herida perineal, estoma y hernia. En la regresión multivariable, la inmunosupresión se asoció con mayores probabilidades de complicaciones de la herida perineal y la derivación preoperatoria no se asoció con la cicatrización de la herida perineal. La enfermedad de Crohn se sospechó en 24 pacientes antes de la operación, pero se confirmó por histopatología en solo 6 pacientes. LIMITACIONES: Revisión retrospectiva del cuadro de la experiencia de una sola institución por la cual las tasas de complicaciones pueden ser subestimadas de las tasas de eventos reales. CONCLUSIONES: La escisión de la bolsa se asocia con una alta morbilidad postoperatoria y una reintervención a largo plazo debido a complicaciones de…
It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer confere... more It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer conference (MCCs), (iii) preoperative radiotherapy, (iv) total mesorectal excision surgery and (v) pathological assessment as described by Quirke are key processes necessary for high quality, rectal cancer care. The objective was to select a set of multidisciplinary quality indicators to measure the uptake of these clinical processes in clinical practice.
Background Patient engagement is the establishment of active partnerships between patients, famil... more Background Patient engagement is the establishment of active partnerships between patients, families, and health professionals to improve healthcare delivery. The objective of this project was to conduct a series of patient engagement workshops to identify areas to improve the surgical experience and develop strategies to address areas identified as high priority. Methods Faculty surgeons and patients were invited to participate in three in-person meetings. Evaluation included identifying and developing strategies for three priority areas to improve the surgical experience and level of engagement achieved at each meeting. Results Sixteen faculty surgeons and 32 patients participated. Some 63 themes to improve the surgical experience were identified; the three highest-priority themes were physician communication, discharge process, and expectations at home after discharge. Individual improvement strategies for these three prioritized themes (12, 36 and 6 respectively) were used to de...
Background Over the last 2 decades, the use of multimodal strategies, including total mesorectal ... more Background Over the last 2 decades, the use of multimodal strategies, including total mesorectal excision (TME) surgery, preoperative chemotherapy, multidisciplinary case conference, pelvic magnetic resonance imaging, and pathologic assessment using Quirke method, has led to significant improvements in oncologic outcomes for patients with rectal cancer. Although the literature supports claims on the effectiveness of these multimodal strategies, the uptake of these multimodal strategies varies considerably among centers, suggesting that the best evidence is not always implemented into clinical practice. Objective This study aims to perform a quality improvement initiative to (1) identify existing gaps in care for these multimodal strategies and (2) implement knowledge translation (KT) interventions to close these gaps to optimize quality of care for patients with rectal cancer across high-volume centers in Canada. Methods Process indicators for the selected multimodal strategies to o...
IMPORTANCE Chemoradiotherapy (CRT), followed by surgery, is the recommended approach for stage II... more IMPORTANCE Chemoradiotherapy (CRT), followed by surgery, is the recommended approach for stage II and III rectal cancer. While CRT decreases the risk of local recurrence, it does not improve survival and leads to poorer functional outcomes than surgery alone. Therefore, new approaches to better select patients for CRT are important. OBJECTIVE To conduct a phase 2 study to evaluate the safety and feasibility of using magnetic resonance imaging (MRI) criteria to select patients with "good prognosis" rectal tumors for primary surgery. DESIGN, SETTING, AND PARTICIPANTS Prospective nonrandomized phase 2 study at 12 high-volume colorectal surgery centers across Canada. From September 30, 2014, to October 21, 2016, a total of 82 patients were recruited for the study. Participants were patients newly diagnosed as having rectal cancer with MRI-predicted good prognosis rectal cancer. The MRI criteria for good prognosis tumors included distance to the mesorectal fascia greater than 1 mm; definite T2, T2/early T3, or definite T3 with less than 5 mm of extramural depth of invasion; and absent or equivocal extramural venous invasion. INTERVENTIONS Patients with rectal cancer with MRI-predicted good prognosis tumors underwent primary surgery. MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients with a positive circumferential resection margin (CRM) rate. Assuming a 10% baseline probability of a positive CRM, a sample size of 75 was estimated to yield a 95% CI of ±6.7%. RESULTS Eighty-two patients (74% male) participated in the study. The median age at the time of surgery was 66 years (range, 37-89 years). Based on MRI, most tumors were midrectal (65% [n = 53]), T2/early T3 (60% [n = 49]), with no suspicious lymph nodes (63% [n = 52]). On final pathology, 91% (n = 75) of tumors were T2 or greater, 29% (n = 24) were node positive, and 59% (n = 48) were stage II or III. The positive CRM rate was 4 of 82 (4.9%; 95% CI, 0.2%-9.6%). CONCLUSIONS AND RELEVANCE The use of MRI criteria to select patients with good prognosis rectal cancer for primary surgery results in a low rate of positive CRM and suggests that CRT may not be necessary for all patients with stage II and III rectal cancer.
Canadian journal of surgery. Journal canadien de chirurgie, 2013
Operative reports (ORs) serve as the official documentation of surgical procedures. They are esse... more Operative reports (ORs) serve as the official documentation of surgical procedures. They are essential for optimal patient care, physician accountability and billing, and direction for clinical research and auditing. Nonstandardized narrative reports are often of poor quality and lacking in detail. We sought to audit the completeness of narrative inguinal hernia ORs. A standardized checklist for inguinal hernia repair (IHR) comprising 33 variables was developed by consensus of 4 surgeons. Five high-volume IHR surgeons categorized items as essential, preferable or nonessential. We audited ORs for open IHR at 6 academic hospitals. We audited 213 ORs, and we excluded 7 femoral hernia ORs. Tension-free repairs were the most common (82.5%), and the plug-and-patch technique was the most frequent (52.9%). Residents dictated 59% of ORs. Of 33 variables, 15 were considered essential and, on average, 10.8 ± 1.3 were included. Poorly reported elements included first occurrence versus recurrent...
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Papers by Amandeep Pooni