RESUMO
AIM: Defaecating proctogram (DP) studies have become an integral part of the evaluation of patients with pelvic floor disorders. However, their impact on treatment decision-making remains unclear. The aim of this study was to assess the concordance of decision-making by colorectal surgeons and the role of the DP in this process. METHOD: Four colorectal surgeons were presented with online surveys containing the complete history, examination and investigations of 106 de-identified pelvic floor patients who had received one of three treatment options: physiotherapy only, anterior Delorme's procedure or anterior mesh rectopexy. The survey assessed the management decisions made by each of the surgeons for the three treatments both before and after the addition of the DP to the diagnostic work-up. RESULTS: After the addition of the DP results; treatment choice changed in 219 (52%) of 424 surgical decisions and interrater agreement improved significantly from κ = 0.26 to κ = 0.39. Three of the four surgeons reported a significant increase in confidence. Agreement with the actual treatments patients received increased from κ = 0.21 to κ = 0.28. Intra-anal rectal prolapse on DP was a significant predictor of a decision to perform anterior mesh rectopexy. CONCLUSION: The DP improves interclinician agreement in the management of pelvic floor disorders and enhances the confidence in treatment decisions. Intra-anal rectal prolapse was the most influential DP parameter in treatment decision-making.
Assuntos
Neoplasias Colorretais , Distúrbios do Assoalho Pélvico , Prolapso Retal , Feminino , Humanos , Prolapso Retal/diagnóstico por imagem , Prolapso Retal/cirurgia , Distúrbios do Assoalho Pélvico/diagnóstico por imagem , Distúrbios do Assoalho Pélvico/terapia , Reto/diagnóstico por imagem , Reto/cirurgia , Tomada de Decisão Clínica , Resultado do TratamentoRESUMO
BACKGROUND: Despite regular surveillance colonoscopy, the metachronous colorectal cancer risk for mismatch repair (MMR) gene mutation carriers after segmental resection for colon cancer is high and total or subtotal colectomy is the preferred option. However, if the index cancer is in the rectum, management decisions are complicated by considerations of impaired bowel function. We aimed to estimate the risk of metachronous colon cancer for MMR gene mutation carriers who underwent a proctectomy for index rectal cancer. METHODS: This retrospective cohort study comprised 79 carriers of germline mutation in a MMR gene (18 MLH1, 55 MSH2, 4 MSH6, and 2 PMS2) from the Colon Cancer Family Registry who had had a proctectomy for index rectal cancer. Cumulative risks of metachronous colon cancer were calculated using the Kaplan-Meier method. RESULTS: During median 9 years (range 1-32 years) of observation since the first diagnosis of rectal cancer, 21 carriers (27 %) were diagnosed with metachronous colon cancer (incidence 24.25, 95 % confidence interval [CI] 15.81-37.19 per 1,000 person-years). Cumulative risk of metachronous colon cancer was 19 % (95 % CI 9-31 %) at 10 years, 47 (95 % CI 31-68 %) at 20 years, and 69 % (95 % CI 45-89 %) at 30 years after surgical resection. The frequency of surveillance colonoscopy was 1 colonoscopy per 1.16 years (95 % CI 1.01-1.31 years). The AJCC stages of the metachronous cancers, where available, were 72 % stage I, 22 % stage II, and 6 % stage III. CONCLUSIONS: Given the high metachronous colon cancer risk for MMR gene mutation carriers diagnosed with an index rectal cancer, proctocolectomy may need to be considered.
Assuntos
Portador Sadio , Neoplasias do Colo/epidemiologia , Neoplasias do Colo/genética , Segunda Neoplasia Primária/epidemiologia , Segunda Neoplasia Primária/genética , Neoplasias Retais/genética , Proteínas Adaptadoras de Transdução de Sinal/genética , Adenosina Trifosfatases/genética , Adolescente , Adulto , Idoso , Austrália/epidemiologia , Canadá/epidemiologia , Neoplasias do Colo/patologia , Enzimas Reparadoras do DNA/genética , Proteínas de Ligação a DNA/genética , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Endonuclease PMS2 de Reparo de Erro de Pareamento , Proteína 1 Homóloga a MutL , Proteína 2 Homóloga a MutS/genética , Mutação , Segunda Neoplasia Primária/patologia , Nova Zelândia/epidemiologia , Proteínas Nucleares/genética , Modelos de Riscos Proporcionais , Neoplasias Retais/cirurgia , Estudos Retrospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: A loop ileostomy is a common adjunct to formation of a low colorectal anastomosis. However, it is not without significant physical and psychological morbidity, and financial cost. Feasibility of early closure during the index admission has previously been reported. This pilot study examines the safety of early closure compared with traditional timing. METHODS: A retrospective audit of consecutive ileostomy closures performed in a tertiary colorectal unit from January 2008 to January 2010. Demographic data, treatment data and complications were collected by a single investigator from a prospective clinical audit database and hospital records. Patients undergoing early closure (within 10 days of the index operation) were compared with the traditional timing group. RESULTS: A total of 93 patients underwent closure of loop ileostomy during the study period (44 female; 49 male). Median patient age was 61 years. Nineteen patients (20%) underwent early closure. There were six wound infections in the early closure group (32%), and five in the traditional timing group (7%) (P = 0.01). There was no significant difference in other complications between the two groups. There was a significantly shorter overall hospital stay in the early closure group with a median stay of 14 days (range 10-26), and in the traditional timing group a median stay of 17 days (range 7-80) (P = 0.05). Seven patients (9%) in the traditional timing group had ileostomy-related complications. CONCLUSION: Early ileostomy closure appears to be associated with an increased wound infection rate but otherwise appears to be a safe alternative to traditional closure in selected patients and may reduce overall hospital stay.
Assuntos
Colo/cirurgia , Ileostomia , Íleo/cirurgia , Reto/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/etiologia , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. This is an update of a Cochrane review first published in 2007. OBJECTIVES: To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications. SEARCH STRATEGY: MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005 and were updated in December 2010. Abstracts presented to the following society meetings between 1970 and 2010 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology. SELECTION CRITERIA: Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults. DATA COLLECTION AND ANALYSIS: Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer inflammatory bowel disease as indication for ileocolic anastomoses were performed. MAIN RESULTS: After obtaining individual data from authors for studies that include other anastomoses, seven trials (including one unpublished) with 1125 ileocolic participants (441 stapled, 684 handsewn) were included. The five largest trials had adequate allocation concealment.Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=11/441, HS=42/684, OR 0.48 [0.24, 0.95] p=0.03). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significantly fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). In subgroup analysis of non-cancer patients (3 studies, 264 patients) there were no differences for any reported outcomes. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference. AUTHORS' CONCLUSIONS: Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.
Assuntos
Colo/cirurgia , Íleo/cirurgia , Grampeamento Cirúrgico , Técnicas de Sutura , Adulto , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Neoplasias Colorretais/cirurgia , Doença de Crohn/cirurgia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Grampeamento Cirúrgico/efeitos adversos , Deiscência da Ferida Operatória/etiologia , Técnicas de Sutura/efeitos adversosRESUMO
BACKGROUND: In accordance with the Bethesda Guidelines, Auckland's metropolitan hospitals routinely perform immunohistochemistry for mismatch repair proteins on the tumor specimens of all patients with colorectal cancer aged 50 years and younger. When loss of expression is evident, patients are offered genetic counseling and gene mutation analysis. OBJECTIVES: This study aimed to determine the completeness of young patient capture over the first 7 years of routine testing, to find whether patients were referred for genetic testing, and to determine the proportion of patients found to have a mismatch repair gene mutation. DESIGN: This study retrospectively reviewed clinical, pathological, and genetic data. SETTINGS: The study was conducted at 3 public hospitals in Auckland, New Zealand. PATIENTS: All patients aged 50 years and younger treated for colorectal cancer at Auckland's metropolitan hospitals between January 2001 and December 2007 (n = 243) were included. MAIN OUTCOME MEASURES: The loss of expression of mismatch repair proteins by immunohistochemistry, referral for genetic testing, and proportion with mismatch repair gene mutation were the main outcome measures. RESULTS: Two hundred fourteen (88%) eligible patients had immunohistochemical analysis of their tumor and 33 (14%) had loss of expression of one or more mismatch repair proteins. Twenty-six patients were referred for genetic counseling, of whom 22 underwent genetic testing. A mismatch repair gene mutation was identified in 10 patients. LIMITATIONS: Seven patients with loss of expression of mismatch repair proteins by immunohistochemistry were not referred for genetic assessment. CONCLUSIONS: We have identified a mismatch repair gene mutation diagnostic of hereditary nonpolyposis colorectal cancer in 5% of all patients with colorectal cancer who were aged 50 years and younger. Routine immunohistochemical prescreening has important clinical benefit for these patients and their relatives.
Assuntos
Pareamento Incorreto de Bases , Biomarcadores Tumorais/análise , Neoplasias Colorretais Hereditárias sem Polipose/diagnóstico , DNA de Neoplasias/análise , Imuno-Histoquímica/métodos , Adolescente , Adulto , Fatores Etários , Biomarcadores Tumorais/genética , Neoplasias Colorretais Hereditárias sem Polipose/epidemiologia , Neoplasias Colorretais Hereditárias sem Polipose/genética , Feminino , Seguimentos , Predisposição Genética para Doença , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Estudos Retrospectivos , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: Surgical management of colon cancer for patients with Lynch syndrome who carry a mismatch repair (MMR) gene mutation is controversial. The decision to remove more or less of the colon involves the consideration of a relatively high risk of metachronous colorectal cancer (CRC) with the impact of more extensive surgery. OBJECTIVE: To estimate and compare the risks of metachronous CRC for patients with Lynch syndrome undergoing either segmental or extensive (subtotal or total) resection for first colon cancer. DESIGN: Risk of metachronous CRC was estimated for 382 MMR gene mutation carriers (172 MLH1, 167 MSH2, 23 MSH6 and 20 PMS2) from the Colon Cancer Family Registry, who had surgery for their first colon cancer, using retrospective cohort analysis. Age-dependent cumulative risks of metachronous CRC were calculated using the Kaplan-Meier method. Risk factors for metachronous CRC were assessed by a Cox proportional hazards regression. RESULTS: None of 50 subjects who had extensive colectomy was diagnosed with metachronous CRC (incidence rate 0.0; 95% CI 0.0 to 7.2 per 1000 person-years). Of 332 subjects who had segmental resections, 74 (22%) were diagnosed with metachronous CRC (incidence rate 23.6; 95% CI 18.8 to 29.7 per 1000 person-years). For those who had segmental resections, incidence was statistically higher than for those who had extensive surgery (P <0.001). Cumulative risk of metachronous CRC was 16% (95% CI 10% to 25%) at 10 years, 41% (95% CI 30% to 52%) at 20 years and 62% (95% CI 50% to 77%) at 30 years after segmental colectomy. Risk of metachronous CRC reduced by 31% (95% CI 12% to 46%; p=0.002) for every 10 cm of bowel removed. CONCLUSIONS: Patients with Lynch syndrome with first colon cancer treated with more extensive colonic resection have a lower risk of metachronous CRC than those receiving less extensive surgery. This finding will better inform decision-making about the extent of primary surgical resection.
Assuntos
Neoplasias Colorretais Hereditárias sem Polipose/genética , Reparo de Erro de Pareamento de DNA/genética , Proteínas Adaptadoras de Transdução de Sinal/genética , Adenosina Trifosfatases/genética , Adulto , Distribuição por Idade , Idoso , Colectomia/métodos , Colonoscopia , Neoplasias Colorretais Hereditárias sem Polipose/patologia , Neoplasias Colorretais Hereditárias sem Polipose/cirurgia , Análise Mutacional de DNA/métodos , Enzimas Reparadoras do DNA/genética , Proteínas de Ligação a DNA/genética , Métodos Epidemiológicos , Feminino , Heterozigoto , Humanos , Masculino , Pessoa de Meia-Idade , Endonuclease PMS2 de Reparo de Erro de Pareamento , Proteína 1 Homóloga a MutL , Proteína 2 Homóloga a MutS/genética , Estadiamento de Neoplasias , Segunda Neoplasia Primária/genética , Segunda Neoplasia Primária/prevenção & controle , Proteínas Nucleares/genética , Distribuição por Sexo , Adulto JovemRESUMO
BACKGROUND: Rectal mucosal advancement flaps (RMAF) and fistula plugs (FP) are techniques used to manage complex anal fistulas. The purpose of this study was to review and compare the results of these methods of repair. METHODS: A retrospective review of all complex anal fistulas treated by either a RMAF or a FP at Auckland City Hospital from 2004 to 2008. Comparisons were made in terms of successful healing rates, time to failure and the use of magnetic resonance imaging. RESULTS: Overall, 70 operations were performed on 55 patients (55.7% male). The mean age was 44.9 years. Twenty-one patients (30%) had had at least one previous unsuccessful repair. Indications for repair included 57 high cryptoglandular anal (81%), 4 Crohn's anal (6%), 7 rectovaginal (10%), 1 rectourethral (1%) and 1 pouch-vaginal fistula (1%). All patients were followed up with a mean of 4.5 months. Forty-eight RMAFs (69% of total) were performed with 16 successful repairs (33%). Twenty-two FPs (31% of total) were performed with 7 successful repairs (32%, P = 0.9). In failed repairs, there was no difference in terms of mean time to failure (RMAF 4.8 months versus FP 4.1 months, P = 0.62). Magnetic resonance imaging was performed in 21 patients (37%) before the repair. The success rate in these patients was 20%. CONCLUSIONS: The results of treatment of complex anal fistulas are disappointing. The choice of operation of either a RMAF or a FP did not alter the poor healing rates of about one third of patients in each group.
Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Mucosa Intestinal/transplante , Fístula Retal/cirurgia , Retalhos Cirúrgicos , Tampões Cirúrgicos , Adulto , Bioprótese , Feminino , Seguimentos , Humanos , Tempo de Internação , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Fístula Retal/diagnóstico , Estudos Retrospectivos , Resultado do Tratamento , CicatrizaçãoRESUMO
AIM: To summarise and evaluate data on the use of total parenteral nutrition (TPN) and associated septic complications at Auckland City Hospital (Auckland, New Zealand) over a 6-year period beginning with appointment of a specialist TPN nurse. METHODS: For each adult patient requiring TPN on an inpatient basis (excluding those in critical care) between January 1998 and December 2003 demographic data, reason for TPN requirement, number of days of TPN administration, type of central venous line used for administration, and frequency of infectious complications were collected prospectively. RESULTS: 498 episodes of TPN were recorded in 484 patients (202 male, median age 60, range 15-89 y). Median duration of TPN administration was 11 (range 1-326) d. Over the 6-year period the number of episodes of TPN per year did not change significantly while median duration of TPN decreased from 14.5 d in 1998 to 8 d in 2003 (p<0.0001). Paralytic ileus following abdominal surgery was the predominant indication for TPN. After 1998, the rate of catheter-related bloodstream infections stabilised at 2 per 1000 TPN days. CONCLUSIONS: These results provide a benchmark for infection rates associated with administration of TPN managed by a Nutrition Support Team in a New Zealand tertiary care hospital.
Assuntos
Nutrição Parenteral Total/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateterismo Venoso Central/enfermagem , Infecção Hospitalar/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Nutrição Parenteral Total/enfermagem , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Anastomotic leakage is the most important complication specific to intestinal surgery. The aim of this study was to review the anastomotic leakage rates in a single Colorectal Unit and to evaluate the risk factors for anastomotic leakage after lower gastrointestinal anastomosis. METHODS: A total of 541 consecutive operations involving anastomoses of the colon and rectum that were carried out between 1999 and 2004 at a single colorectal unit were reviewed. Data concerning 35 variables, relating to patient, tumour and surgical factors, were recorded. Outcomes with respect to anastomotic leakage and mortality were recorded. Data were analysed using univariate and multivariate analyses and odds ratios (OR) calculated. RESULTS: The overall rate of anastomotic leakage was 6.5% (35 of 541). The most frequently carried out operations were right hemicolectomy and anterior resection of the rectum, with leak rates of 2.2 and 7.4%, respectively. Univariate analysis showed that male gender (OR = 3.5), previous abdominal surgery (OR = 2.4), Crohn's disease (OR = 3.3), rectal cancer < or =12 cm from the anal verge (OR = 5.4) and prolonged operating time (OR = 2.8) were factors significantly associated with anastomotic leakage. Male gender, a history of previous abdominal surgery and the presence of a low cancer remained significant after multivariate analysis. The risk of anastomotic leakage increased when two or more risk factors were present (P < 0.01). The overall mortality was 3.7% and was higher in patients with anastomotic leakage (14.3%; P = 0.01). CONCLUSIONS: Male gender, previous abdominal surgery and low rectal cancer are associated with increased anastomotic leakage rates. These have important implications during preoperative patient counselling and decision-making regarding defunctioning stoma formation.
Assuntos
Colo/cirurgia , Neoplasias Colorretais/cirurgia , Deiscência da Ferida Operatória/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/efeitos adversos , Colectomia/efeitos adversos , Colectomia/métodos , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Deiscência da Ferida Operatória/etiologia , Deiscência da Ferida Operatória/cirurgia , Taxa de Sobrevida , Falha de TratamentoRESUMO
BACKGROUND: Access to elective general surgery in New Zealand is governed by clinicians' judgment of priority using a visual analog scale (VAS). This has been criticized as lacking reliability and transparency. Our objective was to describe this judgment in terms of previously elicited cues. METHODS: We asked 60 general surgeons in New Zealand to assess patient vignettes using 8 VAS scales to determine priority. They then conducted judgment analysis to determine agreement between surgeons. Cluster analysis was performed to identify groups of surgeons who used different cues. Multiple regression for the combined surgeons was undertaken to determine the predictability of the 8-scale VAS. RESULTS: Agreement between surgeons was poor (ra=0.48). The cause of poor agreement was mostly due to poor consensus (G) between surgeons in how they weighted criteria. Using cluster analysis, we classified the surgeons into 2 groups: 1 took more account of quality of life and diagnosis, whereas the other group placed more weight on the influence of treatment. The 8-scale VAS showed good predictability in assigning a priority score (R2=0.66). DISCUSSION: The level of agreement reflects surgeons' practice variation. This is exemplified by 2 distinct surgeon groups that differ in how criteria were weighted.
Assuntos
Procedimentos Cirúrgicos Eletivos , Cirurgia Geral , Médicos/psicologia , Padrões de Prática Médica , Humanos , Nova Zelândia , Medição da Dor , Recursos HumanosRESUMO
High-output enterocutaneous fistulas involving an open abdominal wound are a difficult management problem. We report our experience on the use of vacuum dressings. The potential benefits, problems and new recommendations for the use of vacuum dressings in the management of enterocutaneous fistulas are discussed.
Assuntos
Fístula Intestinal/terapia , Curativos Oclusivos , Doença Aguda , Idoso , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Curativos Oclusivos/economia , VácuoRESUMO
BACKGROUND: Localizing the source of severe lower gastrointestinal (GI) bleeding is often difficult but is important to plan the extent of colonic resection. The purpose of the present paper was to audit the Auckland Hospital experience of selective angiography, in localizing lower GI bleeding. METHODS: Patients admitted to Auckland Hospital with rectal bleeding and who subsequently had angiography were evaluated by reviewing their clinical notes and radiological results during a 7-year period (1997-2003). Data collected included demographic details, haemodynamic parameters, change in haemoglobin level, requirement of blood transfusion within 24 h before the procedure, site of the bleeding and pathology. RESULTS: The notes of 88 patients (male, n = 51; median age 69 years, range 8-99 years) were available for review and analysis. The site of bleeding was localized in 38 (51%); 30 of them had bleeding in the right colon or small bowel and eight in the left colon. Positive localization correlated with: haemodynamic instability P < 0.0001; drop in haemoglobin level of > or =50 from previous admission (P = 0.02); transfusion requirement of > or =5 units of blood within 24 h (P < 0.0001). Logistic regression analysis showed transfusion requirement of > or =5 units to achieve haemodynamic stability to be the most powerful predictor of accurate localization (odds ratio, 40). CONCLUSION: Catheter angiography for acute lower GI bleeding will successfully localize a point of bleeding in approximately 50% of patients. The most useful clinical indicator for positive angiography was haemodynamic instability particularly in those who require transfusion of > or =5 units of blood to achieve haemodynamic stability.
Assuntos
Doenças do Colo/diagnóstico por imagem , Hemorragia Gastrointestinal/diagnóstico por imagem , Doença Aguda , Adolescente , Adulto , Idoso , Transfusão de Sangue , Criança , Doenças do Colo/terapia , Embolização Terapêutica , Feminino , Hemorragia Gastrointestinal/terapia , Hemodinâmica/fisiologia , Hemoglobinas/análise , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Análise de RegressãoRESUMO
BACKGROUND: Idiopathic faecal incontinence is a common debilitating problem; the results of surgical treatment are variable with only a small proportion of patients achieving full continence. OBJECTIVES: The aim of this study was to evaluate the long-term outcome of postanal repair in idiopathic faecal incontinence. PATIENTS AND METHODS: Patients who had postanal repair in Auckland between 1994 and 2001 were identified and mailed faecal incontinence severity index (FISI) and faecal incontinence quality of life (FIQOL) questionnaires. Preoperative and postoperative incontinence scores were compared and postoperative quality of life scores were calculated. RESULTS: Forty-seven of the 66 patients who had undergone postanal repair from 1994 to 2001 completed the FIQOL questionnaire. FISI scores were complete on 44 patients. Comparison of preoperative and postoperative FISI scores revealed an improvement with mean scores of 34 and 23, respectively (P = 0.0001). Thirty (68%) patients had improved, including four who were fully continent. Fourteen patients were the same or worse. CONCLUSIONS: Postanal repair provides lasting benefit for the majority of patients with faecal incontinence.
Assuntos
Incontinência Fecal/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Qualidade de Vida , Inquéritos e Questionários , Resultado do TratamentoRESUMO
AIMS: This paper describes the rationale and methodology of a study assessing the reliability of tools for clinical prioritisation (Clinical Priority Assessment Criteria [CPAC]) of patients for elective surgery in New Zealand. METHODS: Surgeons from three specialties (general, vascular, and orthopaedic surgery) completed a computerised evaluation rating clinical vignettes across a range of diagnoses using several priority tools. The study design is described and an outline of the individual tool development and definitions is given. RESULTS: Of the 124 surgeons that participated in this study, 48% (60) were general surgeons, 21% (26) were vascular surgeons and 31% (38) were orthopaedic surgeons. The response rates in the first phase of data collection were 67%, 79%, and 63% for general, vascular, and orthopaedic surgery respectively. Completion rates were high with 100%, 93%, and 98% of the same groupings of surgeons completing the first round evaluations. A further 77% to 89% of the participants from the first round also completed the re-test evaluation. CONCLUSION: This study indicates that assessment of the reliability of CPAC tools currently in use in New Zealand is feasible using a vignette-based approach. In the future, study designs that allow for some face-to-face contact may be preferable for achieving optimal response and completion rates among surgeons. Further work from this study will focus on the individual results for each specialty and examining whether altering ethnicity status in vignettes had any effect on scoring behaviour.
Assuntos
Tomada de Decisões Assistida por Computador , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Alocação de Recursos para a Atenção à Saúde/métodos , Atividades Cotidianas , Efeitos Psicossociais da Doença , Humanos , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/cirurgia , Nova Zelândia , Procedimentos Ortopédicos/estatística & dados numéricos , Medição da Dor , Doenças Vasculares/diagnóstico , Doenças Vasculares/cirurgia , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricosRESUMO
BACKGROUND: Clinical priority assessment criteria (CPAC) are used to generate a score by which patients are prioritized and rationed for elective surgery. It is widely believed that surgeons elevate scores to ensure their patients' acceptance for elective surgery, colloquially called gaming. The purpose of the present paper was therefore to investigate whether there was a temporal trend to an increase in the assigned priority score from the inception of CPAC to the present. METHODS: Priority and weighted inlier equivalent separations (WIES) scores between 23 April 1999 and 23 July 2002 were collected for elective general surgical cases at Auckland Hospital. A total of 5440 cases was retrospectively analysed using multiple regression techniques. Priority score was included as the dependent variable and time as an independent variable. Any change in case complexity over that period was accounted for by including the WIES score as a covariate. Multiple regression was undertaken for the combined surgeons and for individuals. RESULTS: The combined model was statistically significant but accounted for only 17% of the priority score variance. An increase of one WIES unit leads to an increase of 2.7 in priority score (P=0.0001). The relationship of priority score with time was dependent on the surgeon performing the prioritization. However, only half the surgeons had individual models that indicated gaming. CONCLUSIONS: The results show that gaming is occurring but that not all surgeons participate in this. The difference between surgeons' participation in gaming is a potential source of practice variation in the prioritization process.
Assuntos
Procedimentos Cirúrgicos Eletivos , Prioridades em Saúde , Seleção de Pacientes , Padrões de Prática Médica/tendências , Triagem/tendências , Teoria dos Jogos , Humanos , Nova Zelândia , Estudos Retrospectivos , Fatores de TempoRESUMO
OBJECTIVE: A single visual analogue scale is used in New Zealand to prioritise patients for elective general surgery. Although it reflects clinical judgement, it has been criticised for its lack of transparency. We wished to elicit generic criteria used by surgeons for prioritisation of patients for elective general surgery in order to improve the transparency of the visual analogue scale. METHODS: Semi-structured interviews were undertaken with 15 general surgeons. Using the repertory grid method, surgeons were asked to explain their rationale for distinguishing between patients they considered a high, medium or low priority for treatment. Interviews were audiotaped, transcribed and analysed for themes. The accuracy of the thematic analysis was checked using a five-point Likert scale to assess surgeons' agreement with the identified themes. Further testing to check for face, content and construct validity was undertaken with a purposive sample of six surgeons prioritising patient vignettes. RESULTS: Eight major themes were deduced: diagnosis; treatment; patient characteristics; symptomatology and sequelae to date; future complications; quality of life; psychological/emotional impact; and socio-political/logistic factors. The utilisation of these themes by surgeons was confirmed. Tests of collinearity indicated good content validity. Factor analysis confirmed the hypothesis of one underlying construct, namely priority. CONCLUSION: Seven of the themes became the basis for a new clinical priority assessment criteria tool using visual analogue scales to determine priority of patients for elective general surgery. Further testing of reliability and validity is needed.
Assuntos
Atitude do Pessoal de Saúde , Técnicas de Apoio para a Decisão , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Alocação de Recursos para a Atenção à Saúde/métodos , Seleção de Pacientes , Cirurgia Geral , Humanos , Entrevistas como Assunto , Nova Zelândia , Medição da Dor , Avaliação de Processos em Cuidados de Saúde , Qualidade de Vida , Fatores Socioeconômicos , Triagem/métodos , Listas de EsperaRESUMO
INTRODUCTION: Recurrent perianal sepsis is a difficult problem to manage in colorectal surgical practice. One cause is rectal duplication cyst, a rare congenital lesion that is easily overlooked. Many cases have associated congenital defects, especially musculoskeletal anomalies, and may provide a clue to the underlying condition. Early diagnosis is important because these cysts do not resolve spontaneously and may undergo malignant change. METHODS: We present two cases of middle-aged females who presented with perianal sepsis secondary to rectal duplication cyst. The first case had numerous surgical procedures for a perianal fistula during a ten-year period. She had associated sacral anomalies consistent with Currarino syndrome. The second case presented with a perineal mass after a bout of perianal inflammation. Both cases had the entire cyst surgically excised. RESULTS: There were no complications postoperatively and no recurrence at follow-up. Histopathology revealed no malignancy in the cyst. CONCLUSIONS: Rectal duplication cyst is a rare cause of recurrent perianal sepsis that should be considered in difficult cases, especially in those with associated musculoskeletal anomalies. Complete surgical excision is the preferred treatment to prevent recurrence and the risk of malignant degeneration.