Repeat preoperative endoscopy after regional implementation of electronic synoptic endoscopy reporting: a retrospective comparative study.

BACKGROUND: Repeat preoperative endoscopy is common for patients with colorectal neoplasms. This can result in treatment delays, patient discomfort, and risks of colonoscopy-related complications. Repeat preoperative endoscopy has been attributed to poor communication between endoscopists and surgeons. In January 2019, mandatory electronic synoptic reporting for endoscopy was implemented to include elements consistent with quality indicators proposed in national guidelines. The aim of the present study is to assess whether the repeat preoperative endoscopy rate for colorectal lesions changed following synoptic report implementation. METHODS: A retrospective review was performed of 1690 consecutive patients who underwent elective surgical resection for colorectal neoplasms from January 2007 to June 2020 at a tertiary hospital in Canada. Patients who had an index endoscopy documented via synoptic report were compared to those reported via narrative report. Primary outcomes were rates of repeat preoperative endoscopy and inclusion of colonoscopy quality indicators: photo-documentation, tattoo placement, and bowel preparation score. RESULTS: In total, 1429 patients who underwent elective colorectal resection for colorectal cancers or polyps between January 2007 and June 2020 were included. 115 had index endoscopies recorded via synoptic report and 1314 by narrative report. The repeat preoperative endoscopy rate after endoscopies documented by narrative report was 29.07% (95% CI 26.63-31.61) and 25.22% (95% CI 17.58-34.17%) for synoptic report. Patients whose index endoscopies where performed by a practitioner other than their operating surgeon had a re-endoscopy rate of 36.03% (95% CI 32.82-39.33%) after narrative report and 38.81% (95% CI 27.14-51.50%) for synoptic report. Rates of tattoo placement, photo-documentation, and reporting of bowel preparation quality were all significantly increased with synoptic reports (p ≤ 0.003). CONCLUSIONS: Endoscopy synoptic reports based on current guidelines were not associated with a decrease in rates of repeat pre-operative endoscopy at a high-volume colorectal cancer centre. Future study should examine guideline deficiencies for this purpose and make necessary modifications.

Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study.

AIM: 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. METHOD: A multidisciplinary panel was convened and a modified two-phase Delphi method was used to select a set of quality indicators. Phase 1 included a literature review with written feedback from the panel. Phase 2 included an in-person workshop with anonymous voting. The selection criteria for the indicators were strength of evidence, ease of capture and usability. Indicators for which ≥90% of the panel members voted 'to keep' were selected as the final set of indicators. RESULTS: During phase 1, 68 potential indicators were generated from the literature and an additional four indicators were recommended by the panel. During phase 2, these 72 indicators were discussed; 48 indicators met the 90% inclusion threshold and included eight pathology, five radiology, 11 surgical, six radiation oncology and 18 MCC indicators. CONCLUSION: A modified Delphi method was used to select 48 multidisciplinary quality indicators to specifically measure the uptake of key processes necessary for high quality care of patients with rectal cancer. These quality indicators will be used in future work to identify and address gaps in care in the uptake of these clinical processes.

The Association Between Wait Times for Colorectal Cancer Treatment and Health Care Costs: A Population-Based Analysis.

BACKGROUND: Health care costs and wait times for colorectal cancer treatment are increasing in Canada, but the association between the 2 remains unclear. OBJECTIVE: This study aimed to determine the association between wait times and health care costs and utilization. DESIGN: This is a population-based retrospective cohort study. SETTING: This study was conducted in Manitoba, Canada. PATIENTS: Patients diagnosed with colorectal cancer between 2004 and 2014 were sorted and ranked into quintiles based on the time from index contact for a colorectal cancer-related symptom to first treatment. MAIN OUTCOME MEASURES: The primary outcome is risk-adjusted health care costs, and the secondary outcomes include health care utilization and overall mortality. RESULTS: We included a total of 6936 patients. Total wait times ranged between 0 and 762 days. In comparison with very short wait times, longer wait times were associated with significantly increased costs (short: mean cost ratio 1.21; 95% CI, 1.10-1.32; moderate: mean cost ratio 1.30; 95% CI, 1.19-1.43; long: mean cost ratio 1.48; 95% CI, 1.33-1.64; and very long: mean cost ratio 1.39; 95% CI, 1.26-1.54). Compared with very short wait times, longer wait times were associated with significantly lower risk of mortality (short: HR, 0.78; 95% CI, 0.71-0.86; moderate: HR, 0.72; 95% CI, 0.65-0.80; long: HR, 0.73; 95% CI, 0.66-0.82; very long: HR, 0.76; 95% CI, 0.68-0.85). The median number of pretreatment radiological and endoscopic investigations and surgeon clinic visits increased over the study period across all wait time categories. LIMITATIONS: This is a nonrandomized, retrospective cohort study with potentially limited generalizability. CONCLUSION: Patients with very short and short wait times are likely those diagnosed with life-threatening complications of colorectal cancer. Outside this window, patients with longer wait times experience increased health care costs and utilization with similar overall mortality. Improved care coordination and patient navigation may help contain the increasing wait times and associated increasing health care costs and utilization. See Video Abstract at http://links.lww.com/DCR/B81. ASOCIACIÓN ENTRE LOS TIEMPOS DE ESPERA PARA EL TRATAMIENTO DE UN CÁNCER COLORRECTAL Y LOS COSTOS DE ATENCIÓN MÉDICA: UN ANÁLISIS DE POBLACIÓN: los costos de atención médica y los tiempos de espera para el tratamiento del cáncer colorrectal están aumentando en Canadá, pero la asociación entre los dos sigue sin estar clara.determinar la asociación entre los tiempos de espera y los costos y la utilización de la atención médicaun estudio de cohorte retrospectivo basado en la población.Manitoba, Canadálos pacientes diagnosticados con cáncer colorrectal entre 2004-2014 se clasificaron y sub-clasificaron en quintiles según el tiempo desde el primer contacto índice de síntomas relacionados con cáncer colorrectal hasta el primer tratamiento.El resultado primario son los costos de atención médica ajustados al riesgo, y los resultados secundarios incluyen la utilización de la atención médica y la mortalidad general.Incluimos un total de 6,936 pacientes. Los tiempos de espera totales oscilaron entre 0-762 días. En comparación con los tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con costos significativamente mayores (Corto: relación de costo promedio 1.21, intervalo de confianza del 95% 1.10-1.32; Moderado: relación de costo promedio 1.30, intervalo de confianza del 95% 1.19-1.43; Largo: media relación de costo 1.48, intervalo de confianza del 95% 1.33-1.64; Muy largo: relación de costo promedio 1.39, intervalo de confianza del 95% 1.26-1.54). En comparación con tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con un riesgo de mortalidad significativamente menor (Corto: razón de riesgo 0.78, intervalo de confianza del 95% 0.71-0.86; Moderado: razón de riesgo 0.72, intervalo de confianza del 95% 0.65-0.80; Largo: peligro cociente 0.73, intervalo de confianza del 95% 0.66-0.82; Muy largo: cociente de riesgos 0.76, intervalo de confianza del 95% 0.68-0.85). La mediana del número de investigaciones radiológicas y endoscópicas previas al tratamiento y las visitas al cirujano aumentaron durante el período de estudio en todas las categorías de tiempo de espera.estudio de cohortes retrospectivo, no aleatorio con generalización potencialmente limitadalos pacientes con tiempos de espera « muy cortos ¼ y « cortos ¼ son probablemente aquellos diagnosticados con complicaciones potencialmente mortales del cáncer colorrectal. Fuera de esta ventana, los pacientes con tiempos de espera más largos experimentan mayores costos de atención médica y utilización con una mortalidad general similar. La coordinación mejorada de la atención y la navegación del paciente pueden ayudar a contener el aumento de los tiempos de espera y el aumento de los costos y la utilización de la atención médica. Consulte Video Resumen en http://links.lww.com/DCR/B81. (Traducción-Dr. Edgar Xavier Delgadillo).

Training interventions to improve adenoma detection rates during colonoscopy: a systematic review and meta-analysis.

BACKGROUND: Colonoscopies are effective means of detecting and removing precancerous adenomatous polyps. The adenoma detection rate (ADR) is a marker of colonoscopy quality and an independent predictor of colorectal cancer incidence. Focused training interventions may improve an endoscopist's ADR, but the supporting research is limited. This systematic review and meta-analysis identified, critically appraised, and meta-analyzed data from randomized trials (RCTs) evaluating the effect of training interventions on ADRs. METHODS: Ovid Medline, EMBASE, CENTRAL, Eric, CINAHL, Scopus, Web of Science, and ClinicalTrials.gov were searched for RCTs investigating the effect of an educational intervention on ADRs. Two reviewers independently screened, identified, and extracted trial-level data. Internal validity was assessed in duplicate using the Risk of Bias tool. Our primary outcome was the ADR. Secondary outcomes were advanced ADR, adenocarcinoma detection rate, polyp detection rate, and withdrawal times. Safety outcomes were post-polypectomy bleeding rate and colonoscopy-related perforation rate. RESULTS: From 2837 screened citations, we identified 3 trials (119 endoscopists) meeting our inclusion criteria. Training interventions were associated with a trend toward increased ADRs (odds ratio 1.16, 95% confidence interval (CI) 1.00-1.34; I2 83%; 3 trials; 119 endoscopists). When limited to screening colonoscopies, the odds ratio for ADRs associated with training interventions was 1.17 (95% CI 1.00-1.36; I2 80%; 3 trials; 119 endoscopists). There was a high level of heterogeneity between the trials' training interventions. Training intervention improved the advanced ADR, adenocarcinoma detection rate, polyp detection rate, and withdrawal times. Safety outcomes were not reported. CONCLUSIONS: A focused training intervention was associated with a strong trend toward increased ADRs among certified endoscopists. While the described training interventions definitely show promise, further efforts around continuing professional developments activities are needed to more consistently improve ADRS among certified endoscopists.

Timing of Palliative Care in Colorectal Cancer Patients: Does It Matter?

BACKGROUND: Palliative care can improve end-of-life care and reduce health care expenditures, but the optimal timing for initiation remains unclear. We sought to characterize the association between timing of palliative care, in-hospital deaths, and health care costs. METHODS: This is a retrospective cohort study including all patients who were diagnosed and died of colorectal cancer between 2004 and 2012 in Manitoba, Canada. The primary exposure was timing of palliative care, defined as no involvement, late involvement (less than 14 d before death), early involvement (14 to 60 d before death), and very early involvement (>60 d before death). The primary outcome was in-hospital deaths and end-of-life health care costs. RESULTS: A total of 1607 patients were included; 315 (20%) received palliative care and 162 (10%) died in hospital. Compared to those who did not receive palliative care, patients with early and very early involvement experienced significantly decreased odds of dying in hospital (OR 0.21 95% CI 0.06-0.69 P = 0.01 and OR 0.11 95% CI 0.01-0.78 P = 0.03, respectively) and significantly lower health care costs. There were no significant differences in in-hospital deaths and health care costs between patients without palliative care and those who received late palliative care. CONCLUSIONS: Early palliative care involvement is associated with decreased odds of dying in hospital and lower health care utilization and costs in patients with colorectal cancer. These findings provide real-world evidence supporting early integration of palliative care, although the optimal timing (early versus very early) remains a matter of debate.

Synoptic operative reports enhance documentation of best practices for rectal cancer.

BACKGROUND: Implementation of best practices surgical checklists improves patient safety and outcomes. However, documenting performance of these practices can be challenging. The American Society of Colon and Rectal Surgeons developed a Best Practices for Rectal Cancer Checklist (RCC) to standardize and improve the quality of rectal cancer surgery. This study compared the degree to which synoptic (SR) and narrative (NR) operative reports document RCC items. METHODS: Two reviewers independently reviewed a cohort of prospectively collected SR for rectal cancer surgery and a case-matched historical cohort of NR. Reports were reviewed for documentation of performance of operative items on the RCC. Abstraction time and inter-rater agreement were also measured. RESULTS: SR scored significantly higher than NR on the overall checklist score (mean adjusted score ± standard deviation 12.4 ± 0.9 vs. 5.7 ± 1.9, maximum possible score 18, P < 0.001). Reviewers abstracted data significantly faster from SR. Inter-rater agreement between reviewers was high for both types of reports. CONCLUSIONS: SR were associated with reliable and more complete and reliable documentation of items on the RCC. Use of an SR system standardizes operative reporting, providing the opportunity to enhance checklist compliance, and enable timely feedback to improve surgical outcomes for rectal cancer patients.

Diagnosis of VTE postdischarge for major abdominal and pelvic oncologic surgery: implications for a change in practice.

BACKGROUND: Extended thromboprophylaxis after hospital discharge following cancer surgery has been shown to reduce the incidence of venous thromboembolism (VTE); however, this practice has not been universally adopted. We conducted a population-based analysis to determine the proportion of patients with symptomatic VTE diagnosed within 90 days after initial discharge following major abdominopelvic cancer surgery who might have benefited from extended thromboprophylaxis. METHODS: We used the Manitoba Cancer Registry to identify patients who underwent major abdominopelvic cancer surgery between 2004 and 2009. The proportion in whom VTE was diagnosed during the initial hospital stay was determined by accessing the Hospital Separations Abstracts. The proportion in whom VTE was diagnosed after discharge was determined by examining repeat admissions within 90 days and by accessing Drug Programs Information Network records for newly prescribed anticoagulants. Detailed tumour and treatment-specific data allowed calculation of VTE predictors. RESULTS: Of 6612 patients identified, 106 (1.60%) had VTE diagnosed during the initial stay and 96 (1.45%) presented with VTE after discharge. Among patients in whom VTE developed after discharge, 33.3% had a pulmonary embolus, 24% had deep vein thrombosis, and 6.3% had both. Predictors of presenting with VTE after discharge within 90 days of surgery included advanced disease, presence of other complications, increased hospital resource utilization, primary tumours of noncolorectal gastrointestinal origin and age younger than 45 years. The development of VTE was an independent predictor of decreased 5-year overall survival. CONCLUSION: The cumulative incidence of VTE within 90 days of major abdominopelvic oncologic surgery was 3.01%, with about half (1.45%) having been diagnosed within 90 days after discharge.

CONTEXTE: La thromboprophylaxie prolongée après le congé hospitalier suite à une chirurgie pour cancer a permis de réduire l'incidence de la thrombo-embolie veineuse (TEV); or, cette pratique n'a pas été universellement adoptée. Nous avons procédé à une analyse de population afin de déterminer la proportion de patients qui ont reçu un diagnostic de TEV symptomatique dans les 90 jours suivant leur congé à la suite d'une chirurgie majeure pour cancer abdomino-pelvien et qui auraient pu bénéficier d'une thromboprophylaxie prolongée. MÉTHODES: Nous avons utilisé le registre du cancer du Manitoba pour recenser les patients ayant subi une chirurgie majeure pour cancer abdomino-pelvien entre 2004 et 2009. La proportion de patients chez qui une TEV a été diagnostiquée au cours du séjour hospitalier initial a été calculée à partir des sommaires d'hospitalisation préparés au congé du patient. La proportion de patients chez qui la TEV a été diagnostiquée après le congé provient de l'examen des dossiers de réadmission dans les 90 jours et du réseau provincial d'information sur les programmes de médicaments pour les anticoagulants nouvellement prescrits. L'analyse des données détaillées sur les tumeurs et les traitements a permis d'établir les prédicteurs de la TEV. RÉSULTANTS: Sur 6612 patients recensés, 106 (1,60 %) ont reçu un diagnostic de TEV durant leur séjour initial et 96 (1,45 %), après leur congé. Parmi les patients chez qui la TEV est survenue après le congé, 33,3 % ont souffert d'une embolie pulmonaire, 24 %, d'une thrombose veineuse profonde et 6,3 %, des deux. Les prédicteurs de la TEV consécutive au congé hospitalier dans les 90 jours suivant une chirurgie incluaient : maladie avancée, présence d'autres complications, utilisation accrue des ressources hospitalières, tumeur primitive d'origine gastro-intestinale non colorectale et âge < 45 ans. La TEV s'est révélée être un prédicteur indépendant d'une plus brève survie globale à 5 ans. CONCLUSION: L'incidence cumulative des TEV dans les 90 jours suivant une chirurgie majeure pour cancer abdomino-pelvien a été de 3,01 %, environ la moitié des cas (1,45 %) ayant été diagnostiqués dans les 90 jours suivant le congé.

Is obesity associated with advanced stage or grade of colon cancer?

Population-based studies from Europe have suggested that obesity is associated with more advanced stage colorectal cancer on presentation. Obesity is an even more prevalent issue in North America, but comparable data on associations with cancer are lacking. We reviewed the cases of 672 patients with colon cancer diagnosed between 2004 and 2008 in the province of Manitoba who underwent surgical resection at a Winnipeg Regional Health Authority­affiliated hospital. We tested if obesity was associated with more advanced cancer stage or grade. On multivariate analysis, after adjusting for age, sex,tumour location and socioeconomic status, we were unable to show any significant associations between body mass index of 30 or more and advanced stage or grade cancer on presentation. The reasons for the lack of association are likely multifactorial, including the pathophysiology of the disease and process factors, such as screening habits and colonoscopic diagnostic success rates in obese patients.

Documentation of quality of care data for colon cancer surgery: comparison of synoptic and dictated operative reports.

BACKGROUND: Operative reports are a source of clinical data that can, for quality assurance purposes, be used to document the performance of processes that affect the care of surgical patients. We assessed the degree to which synoptic reports document operative quality indicators for colon cancer surgery. METHODS: Two reviewers independently reviewed 80 prospectively collected synoptic colon cancer operative reports and a case-matched historical cohort of 80 dictated reports. Reviewers rated how well reports documented performance of quality of care indicators using two checklists of previously validated, colon cancer-specific quality measures. Interrater agreement and time to extract data were also recorded. RESULTS: Synoptic reports had significantly higher overall scores on the quality indictors in comparison to dictated reports for both checklist 1 [mean adjusted score ± standard deviation 18.6 ± 1.3 vs. 9.2 ± 3.6, p < 0.01 (maximum score 38)] and checklist 2 [2.0 ± 0.3 vs. 1.3 ± 1.1, p < 0.01 (maximum score 3)]. Interrater agreement was significantly higher between synoptic reports for both checklists (data not shown). Data were extracted significantly more quickly from synoptic reports than dictated reports [mean time (minutes:seconds) ± standard deviation 2:32 ± 0:44 vs. 4:01 ± 1:14, p < 0.01]. CONCLUSIONS: Synoptic reports were associated with more complete documentation of quality indicators for colon cancer resection compared to dictated reports. Although synoptic reports may improve the documentation of quality of care data, further refinement may help to better document performance of quality measures and improve reporting standards.

Does young age influence the prognosis of colorectal cancer: a population-based analysis.

BACKGROUND: Controversy exists whether young patients diagnosed with colorectal cancer have a poorer prognosis. Although younger patients are more likely to have certain poor prognostic factors, prior studies have shown mixed results in terms of overall prognosis, which may be due to lack of adjustment for confounding factors. The primary objective of our study was to determine the effect of age on survival following treatment of colorectal cancer in the Province of Manitoba, Canada, while controlling for important cofactors. METHODS: This was a population-based analysis of all adult patients (age≥18 years) diagnosed with adenocarcinoma of the colon or rectum between 1 January 2004 and 31 December 2006 in the Province of Manitoba. Patient, tumor, and treatment factors were identified using administrative data. Five-year Kaplan-Meier survival and Cox proportional hazards model were analyzed to determine whether young age (45 years of age or younger) was associated with a poorer prognosis, while controlling for confounding variables. RESULTS: Of the 2,086 patients identified, 70 (3.36%) were considered young. These patients were more likely to have T4 tumors and node-positive disease. Older patients had more advanced comorbidities. Young age was an independent predictor of better survival. Poorer survival was associated with male gender, increasing stage, higher grade, comorbidity, lower socioeconomic status, and lack of receipt of surgery or chemotherapy. CONCLUSIONS: Young people make up a small minority of patients with colorectal cancer. Young patients present with more locally advanced colorectal cancer. Despite this, on a population basis, their prognosis may be more favorable than their older counterparts when controlling for disease, patient, and treatment factors.

The location of surgical care for rural patients with rectal cancer: patterns of treatment and patient perspectives.

BACKGROUND: Where cancer patients receive surgical care has implications on policy and planning and on patients' satisfaction and outcomes. We conducted a population- based analysis of where rectal cancer patients undergo surgery and a qualitative analysis of rectal cancer patients' perspectives on location of surgical care. METHODS: We reviewed Manitoba Cancer Registry data on patients with colorectal cancer (CRC) diagnosed between 2004 and 2006. We interviewed rural patients with rectal cancer regarding their preferences and the factors they considered when deciding on treatment location. Interview data were analyzed using a grounded theory approach. RESULTS: From 2004 to 2006, 2086 patients received diagnoses of CRC in Manitoba (colon: 1578, rectal: 508). Among rural patients (n = 907), those with rectal cancer were more likely to undergo surgery at an urban centre than those with colon cancer (46.5% v. 28.8%, p < 0.001). Twenty rural patients with rectal cancer participated in interviews. We identified 3 major themes from the interview data: the decision-maker, treatment factors and personal factors. Participants described varying input into referral decisions, and often they did not perceive a choice regarding treatment location. Treatment factors, including surgeon factors and hospital factors, were important when considering treatment location. Personal factors, including travel, support, accommodation, finances and employment, also affected participants' treatment experiences. CONCLUSION: A substantial proportion of rural patients with rectal cancer undergo surgery at urban centres. The reasons are complex and only partly related to patient choice. Further studies are required to better understand cancer system access in geographically dispersed populations and to support cancer patients through the decision-making and treatment processes.

CONTEXTE: Le lieu où les patients atteints du cancer subissent une intervention chirurgicale a des répercussions sur les politiques et la planification, et sur la satisfaction du patient et ses résultats. Nous avons étudié dans une population le lieu où des patients atteints de cancer du rectum subissent leur chirurgie et effectué une analyse qualitative des points de vue exprimés par les patients au sujet du lieu où les soins chirurgicaux sont dispensés. MÉTHODES: Nous avons consulté le Registre du cancer du Manitoba pour trouver des données sur des patients atteints de cancer colorectal diagnostiqué entre 2004 et 2006. Nous avons interviewé des patients de régions rurales atteints de cancer du rectum pour connaître leurs préférences et les facteurs dont ils avaient tenu compte en choisissant le lieu où ils allaient être traités. Nous avons analysé les données recueillies à l'aide d'une méthode théorique fondées sur les faits. RÉSULTATS: Entre 2004 et 2006, au Manitoba, 2086 patients ont reçu un diagnostic de cancer colorectal (cancer du côlon : 1578; cancer du rectum : 508). Parmi les patients qui vivaient en milieu rural (n = 907), ceux atteints d'un cancer du rectum avaient plus tendance à subir leur chirurgie dans un établissement urbain que ceux atteints de cancer du côlon (46,5 % c. 28,8 %, p < 0,001). Vingt patients de milieu rural atteitns de cancer du rectum ont participé aux entrevues. Trois principaux éléments se dégagent des données recueillies : le décideur, des facteurs reliés au traitement et des facteurs d'ordre personnel. Les participants ont décrit diverses contributions qu'ils ont apportées à la décision relative à la référence de leur cas et dit que souvent, ils n'ont pas senti qu'un choix de lieux de traitement leur était offert. Les facteurs liés au traitement lui-même, y compris ceux liés au chirurgien et à l'hôpital, ont été importants dans le choix du lieu de traitement. Les facteurs d'ordre personnel, dont le déplacement, le soutien, l'hébergement, la situation financière et l'emploi ont aussi influé sur l'expérience thérapeutique des participants. CONCLUSION: Une proportion considérable de patients atteints du cancer du rectum et vivant en milieu rural subissent leur chirurgie dans des établissements urbains. Les raisons sont complexes et ne sont qu'en partie reliées au choix du patient. Il faudrait mener d'autres études pour mieux comprendre l'accès aux services offerts aux personnes atteintes de cancer dans les populations géographiquement dispersées et pour les appuyer dans le processus de prise de décision et de traitement.

Early Surveillance Endoscopy Should Be Performed Selectively After Transanal Endoscopic Microsurgery for Rectal Lesions.

Introduction Local recurrence (LR) rates after transanal endoscopic microsurgery (TEM) are unclear, and the utility of early postoperative surveillance for low-risk lesions is unknown. This study aimed to define LR after TEM for benign polyps and invasive adenocarcinoma, describe risk factors for LR, and evaluate the utility of early surveillance endoscopy. Methods This retrospective cohort study was conducted at two hospitals in Winnipeg, Manitoba, Canada. Adult patients who underwent TEM between 2009 and 2020 were evaluated for inclusion. The primary outcome was the rate of LR on surveillance endoscopy. Other outcomes included risk factors for LR and diagnostic yield of surveillance endoscopy. Results Among 357 patients who underwent TEM for benign polyps, LR was 10.5% (95% confidence interval (CI) 5.8-15.2) at three years. Positive margin was correlated with LR on multivariate analysis (hazard ratio (HR) 8.01, 95% CI 2.78-23.08). TEM defect closure was associated with lower LR on multivariate analysis (HR 0.19, 95% CI 0.06-0.59). Among 124 patients who underwent TEM for rectal adenocarcinoma, LR was 15.0% (95% CI 6.0-24.0) at three years. The first surveillance endoscopy had a 1.4% yield for low-risk patients (benign lesion, negative margins, and closed TEM defect) and 6.9% for all others. Conclusions LR at three years after TEM was 10.5% for benign polyps and 15.0% for adenocarcinomas. Early surveillance endoscopy can be considered low yield in some patients after TEM, which can be informative for shared decision-making regarding whether to proceed with early endoscopy in a low-risk subgroup of patients.

Geographical disparities of rectal cancer local recurrence and outcomes: a population-based analysis.

BACKGROUND: Challenges exist in providing high-quality cancer treatments to populations spread over large geographical areas. Local recurrence of rectal cancer is a complicated clinical problem associated with high morbidity and mortality. OBJECTIVES: objectives of this study were to evaluate population-based rates and predictors of local recurrence of rectal cancer in the Province of Manitoba, Canada, with emphasis on the effects of geography. DESIGN: : This was a population-based retrospective analysis. Administrative data from the Manitoba Cancer Registry and individual patient charts were reviewed. SETTINGS: Patients with stages I to III rectal cancer who underwent surgery with curative intent in Manitoba between 2004 and 2006 were included. MAIN OUTCOME MEASURES: The primary outcome was the development of local recurrence after surgical resection. RESULTS: Three hundred seventy patients with a mean age of 67 years were identified. The 5-year local recurrence rate was 17.4%. In multivariate analysis, relative to Winnipeg residents, rural residents, regardless of where they underwent surgery, had an increased risk of local recurrence (HR, 3.47; 95% CI, 1.74-6.92 for surgery in Winnipeg; HR, 2.98; 95% CI, 1.59-5.57 for surgery in rural Manitoba). The absence of both neoadjuvant radiotherapy and adjuvant chemotherapy was associated with a higher risk of local recurrence. Higher risk of mortality was noted for rural patients (HR, 1.90; 95% CI, 1.24-2.89) and for those who developed local recurrence (HR, 2.01; 95% CI, 1.27-3.19). CONCLUSION: Local recurrence rates for rectal cancer are high in Manitoba. Geography is an important variable, because rural status is associated with higher local recurrence rates and decreased survival. The use of neoadjuvant radiotherapy was an important predictor of lower local recurrence rates. Further initiatives are imperative to identify why rural patients experience differences in outcomes in Manitoba.

Longer waiting times for patients undergoing colorectal cancer surgery are not associated with decreased survival.

BACKGROUND AND OBJECTIVES: Wait times are a growing concern in Canada's publicly-funded healthcare system. We sought to determine if increased wait times for colorectal cancer (CRC) treatments resulted in worse outcomes. METHODS: A population-based retrospective cohort analysis of wait times for CRC patients undergoing major surgical resections in Manitoba, Canada, between 2004 and 2006 was undertaken. Administrative records were utilized to estimate total wait time (TWT), defined as the sum of time from index contact with the healthcare system to diagnosis of CRC (diagnostic wait time [DWT]) and the time from diagnosis to first cancer treatment (treatment wait time [TxWT]). Multivariate Cox regression analysis of 5-year overall survival was performed to determine the effect of TWT quartiles on survival. RESULTS: One thousand six hundred twenty eight patients with stage I-IV CRC underwent major surgery with a median TWT of 95 days. Predictors of lower 5-year survival included advanced age, higher stage, lower economic status, increased medical comorbidity, urgent presentation, living between 101 and 500 km from the Provincial cancer center, and not receiving adjuvant chemotherapy. After controlling for these variables, TWT quartiles were not associated with survival (P = 0.4898). CONCLUSIONS: On a population basis, increased TWT was not associated with worse survival, while controlling for important confounders.

Does geography influence the treatment and outcomes of colorectal cancer? A population-based analysis.

BACKGROUND: The Canadian province of Manitoba covers a large geographical area but only has one major urban center, Winnipeg. We sought to determine if regional differences existed in the quality of colorectal cancer care in a publicly funded health care system. METHODS: This was a population-based historical cohort analysis of the treatment and outcomes of Manitobans diagnosed with colorectal cancer between 2004 and 2006. Administrative databases were utilized to assess quality of care using published quality indicators. RESULTS: A total of 2,086 patients were diagnosed with stage I to IV colorectal cancer and 42.2% lived outside of Winnipeg. Patients from North Manitoba had a lower odds of undergoing major surgery after controlling for other confounders (odds ratio (OR): 0.48, 95% confidence interval (CI): 0.26 to 0.90). No geographic differences existed in the quality measures of 30-day operative mortality, consultations with oncologists, surveillance colonoscopy, and 5-year survival. However, there was a trend towards lower survival in North Manitoba. CONCLUSION: We found minimal differences by geography. However, overall compliance with quality measures is low and there are concerning trends in North Manitoba. This study is one of the few to evaluate population-based benchmarks for colorectal cancer therapy in Canada.

Effect of an acute care surgical service on the timeliness of care.

BACKGROUND: In the spring of 2008, St. Boniface General Hospital in Winnipeg, Man., created an acute care surgical service (ACSS) designed to improve care for emergent, nontrauma surgical patients. We sought to assess the effect of the ACSS on patient care timeliness. METHODS: We retrospectively examined the time intervals in care for patients admitted with acute appendicitis, acute cholecystitis and small bowel obstruction in 3 study periods: pre-ACSS, newly formed ACSS and established ACSS. RESULTS: There was a 2-fold increase in patient volume after the ACSS was created. Patient characteristics were similar in all 3 groups. Time from triage to surgical consultation was also similar. The ACSS significantly reduced the duration of the surgical consultation (1 h 43 min in period 1 v. 62 min in period 2 and 49 min in period 3, p = 0.029). Time from admission to operation was similar despite a significant increase in patient load after the ACSS was created. Total length of hospital stay was similar except in the subgroup analysis (appendicitis + cholecystitis only), where the length of stay was reduced after creation of the ACSS (2 d 15 h pre- v. 1 d 19 h post-ACSS, p = 0.009). Most operations occurred between 4 pm and midnight. CONCLUSION: With the implementation of an ACSS, the number of surgical patients assessed and treated doubled. Despite the increased volume, consultations were completed significantly faster, there was no significant difference in time to operation, and on subgroup analysis length of hospital stay was significantly faster.

CONTEXTE: Au printemps 2008, l'Hôpital général de Saint-Boniface, à Winnipeg, au Manitoba, s'est doté d'un service de chirurgie de courte durée (SCCD) dans le but d'améliorer les soins aux patients qui doivent subir une chirurgie urgente non d'origine traumatique. Nous avons voulu mesurer l'impact du SCCD sur la rapidité avec laquelle les patients ont eu accès aux soins requis. MÉTHODES: Nous avons examiné de manière rétrospective combien de temps les patients admis pour appendicite aiguë, cholécystite aiguë et obstruction du grêle ont attendu avant de recevoir leur traitement au cours de 3 périodes distinctes : avant la création du SCCD, au moment de son déploiement et depuis son établissement. RÉSULTANTS: On a noté que le volume de patients traités a doublé après la création du SCCD. Les caractéristiques des patients des 3 groupes étaient similaires. Les délais entre le triage et la consultation en chirurgie étaient également similaires. Le SCCD a significativement abrégé la durée de la consultation en chirurgie (soit de 1 h 43 minà la période 1 c. 62 min à la période 2 et 49 min à la période 3, p = 0,029). Le délai entre l'admission et l'intervention est resté similaire malgré l'augmentation significative du nombre de patients après la création du SCCD. La durée totale du séjour hospitalier est restée inchangée, sauf dans l'analyse des sous-groupes (appendicite + cholécystite seulement), selon laquelle la durée du séjour a diminué après la création du SCCD (2 j 15 h pré-SCCD c. 1 j 19 h après SCCD, p = 0,009). La plupart des interventions ont été effectuées entre 16 heures et minuit. CONCLUSIONS: Avec la mise en place d'un SCCD, le nombre de patients de chirurgie évalués et traités a doublé. Et malgré cet accroissement de volume, les consultations ont eu lieu significativement plus rapidement. On n'a noté aucune différence significative quant au délai précédant l'intervention et à l'analyse des sous-groupes, la durée des hospitalisations a été significativement plus brève.

Attending surgeon burnout and satisfaction with the establishment of a regional acute care surgical service.

BACKGROUND: Establishment of the Acute Care Surgical Service (ACSS) has dramatically changed the management of acute, nontrauma surgical patients in Winnipeg, Manitoba. Its formation was partially driven by increasing strain on surgeons and surgical services. We sought to determine surgeon level of burnout and satisfaction with the ACSS. METHODS: All Winnipeg ACSS surgeons were mailed surveys. Burnout was established using the Maslach Burnout Inventory Human Services Survey. Satisfaction was ascertained with a series of questions. RESULTS: We attained a response rate of 76%. Most surgeons were married men with children. A burnout level of 61% was determined. Although most surgeons felt the ACSS was a positive change in their careers, they felt that operating room accessibility and teaching opportunities were lacking. CONCLUSION: Although a high level of burnout exists among ACSS surgeons, most are satisfied with its establishment. Factors such as operating room accessibility and teaching opportunities must be addressed.

Ruptured Middle Colic Artery Aneurysm Presenting with Symptoms of Acute Cholecystitis: A Case Report and Literature Review.

Background: Ruptured middle colic artery aneurysm is extremely uncommon. Diagnosis can be challenging, as symptomatology can be attributed to more common abdominal pathologies. Due to the rarity of this condition, only case reports are available to inform management. Case Presentation: We present the case of a 72-year-old woman with a ruptured middle colic artery aneurysm presenting with signs and symptoms more suggestive of acute calculous cholecystitis. Her co-existing bleed was confirmed on CT angiogram. Coil embolization was initially attempted unsuccessfully. She underwent laparotomy, a middle colic artery ligation, and extended right hemicolectomy with intra-aortic balloon placement for emergency proximal vascular control. Post-operatively, she had a re-bleed that was successfully managed with covered stent placement in the proximal superior mesenteric artery after an unsuccessful re-attempt at coil embolization. Her apparent associated cholecystitis was managed with antibiotics and resolved uneventfully. Conclusion: A middle colic artery aneurysm can be challenging to diagnose and treat. Management options include endovascular techniques, open surgery, or a combination approach. Intra-aortic balloon placement for emergency vascular control is a novel approach that could avoid hemorrhage when intra-abdominal vascular access is challenging.

Routine pathologic evaluation of circular stapler anastomotic rings is not useful after resection for colorectal cancer: retrospective study and systematic review with meta-analysis.

BACKGROUND: Circular staplers are commonly used for reconstruction after radical resection for colorectal cancer. Pathological analysis of the anastomotic rings is common practice, although the benefits are unclear. The purpose of this study was to evaluate the usefulness of routine histopathological analysis of anastomotic rings in an original series and in a systematic review of the literature. METHOD: The retrospective study was performed at two university-associated academic hospitals in Winnipeg, Canada, including patients investigated for colorectal cancers (within 30 cm of the anal verge) who underwent resection between 2007 and 2020. The systematic review involved Ovid MEDLINE, Embase, Scopus, and Web of Science databases, selecting for adult human studies involving analysis of anastomotic rings in elective colorectal cancer resections. The main outcome measure was the proportion of patients with cancer in the anastomotic ring specimens. The frequency of benign pathology findings and changes to patient management were also examined. RESULTS: Out of 673 eligible patients, 487 were included in the retrospective analysis. No patients had cancer within the anastomotic ring specimens. Twenty-five patients (5.1 per cent) had benign pathological findings within the anastomotic ring specimens, and patient management was never affected. In the systematic review, 27 articles were included in the final analysis out of 5848 records reviewed. The rate of cancer within anastomotic ring specimens was 0.34 per cent, and the rate of change in patient management was 0.19 per cent. CONCLUSION: The likelihood of finding cancer within anastomotic rings is rare and their histopathological examination seldom changes patient management.

Cost Analysis of Laparoscopic Low Anterior Resection vs. Transanal Endoscopic Microsurgery for Rectal Neoplasms.

Despite the increasing application of transanal endoscopic microsurgery (TEM) for rectal lesions, the cost of the equipment may play a role in a hospital's hesitancy to invest in the platform. This study compares the cost of TEM to laparoscopic low anterior resection (LAR). Patients who underwent laparoscopic LAR (n = 24) for rectal neoplasm between 2006 and 2014 were case-matched based on sex, age, comorbidities, lesion size and location to patients who underwent TEM at a busy secondary care urban hospital. Procedure-related costs and costs associated with readmissions for complications and related subsequent surgeries in the first 3 years were calculated. There were 42 hospital admissions for 24 LAR patients, totalling 326 hospital days. For 24 TEM patients, there were 25 hospital admissions, totalling 56 hospital days. Subsequent operations for LAR patients included 2 washout and diverting ileostomies (8%), 2 adhesionolysis (8%), 4 ventral hernia repairs (16%) and 11 ileostomy reversals (46%). In the TEM group, there was one operation for recurrence (4%). The mean cost of LAR, including all related hospital costs in the subsequent 3 years, was CAD 14,851 (95% CI: CAD 10,124-19,579). The mean cost of TEM was CAD 2449 (95% CI: CAD 2133-2767; p < 0.0001), with a savings of CAD 12,402 per patient. TEM for rectal neoplasm is associated with significantly lower hospital costs, which far outweigh the costs of acquiring and maintaining the technology.