Intermediate and long-term outcomes of a bowel management program for children with severe constipation or fecal incontinence.

PURPOSE: We sought to examine the long-term clinical success rates of a bowel management program (BMP) for children with severe constipation or fecal incontinence. METHODS: A single center review was conducted of children (≤18 years) enrolled in a BMP and followed in a colorectal specialty clinic (2011-2017). All patients who completed an initial week of the BMP were included. Patients enrolled in a BMP after 2018 were excluded. Success was defined as no accidents and <2 stool smears per week. RESULTS: A total of 285 patients were reviewed. BMP was initiated at a median age of 7 years (9 months-17 years). Primary diagnoses included functional constipation (112), anorectal malformation (ARM) (104), Hirschsprung Disease (HD) (41), rectal prolapse (14), spina bifida (6), fecal incontinence (3) and other (5; 4 sacral coccygeal teratomas and a GSW to the buttocks). Initial bowel regimen included large volume enema in 54% and high dose stimulant laxative in 46%. The initial Bowel Management Week (BMW) was successful in 233 (87% of adherent patients) patients with 17 (6%) non-adherent. One hundred twenty-two patients had follow-up at 12 months (72% success amongst adherent patients, 7% of patient non-adherent) and 98 patients had follow-up at 24 months (78% success amongst adherent patients, 10% of patients non-adherent). 21/154 (14%) patients started on enemas were later successfully transitioned to laxatives and 13/132 (10%) patients started on laxatives subsequently required enemas in order to stay clean. Clinic phone contact occurred outside of scheduled visits for adjustment to the BMP in 44% of patients. 33% of patients had surgery to aid bowel management (antegrade colonic enema (ACE) = 81, resection + ACE = 13, diverting stoma = 4). Median follow up was 2.5 years (5 weeks-7 years). CONCLUSION: Children who follow a structured BMP with readily available personnel to provide outpatient assistance can experience successful treatment of severe constipation or fecal incontinence long-term. A multi-institutional collaboration is necessary to identify factors which predict failure of a BMP and non-adherence. TYPE OF STUDY: Single-center retrospective chart review. LEVEL OF EVIDENCE: 3.

Operative treatment for intussusception: Should an incidental appendectomy be performed?

BACKGROUND/OBJECTIVES: An incidental appendectomy is performed by some surgeons during operative treatment for intussusception to eliminate future appendicitis as a diagnostic consideration. However, an appendectomy can increase the risk of infection and other noninfectious complications making an incidental appendectomy controversial. We examined outcomes for surgical intervention for intussusception with appendectomy (SWA) compared to surgical reduction alone (SRA). METHODS: The Pediatric Health Information System database, 8/2008-9/2015, was retrospectively analyzed for patients under the age of five who required an operative intervention for intussusception without bowel resection. Demographic data and postoperative outcomes were analyzed. Available data included need for postoperative enema, subsequent small bowel obstruction, recurrent intussusception, length of stay (LOS), and adjusted total cost (ATC). RESULTS: Fifty-seven percent (748/1312) of patients had appendectomy performed during surgical reduction, 564 (43%) did not. ATC ($10,594 vs. $8939, p < 0.001) and LOS (3.0 vs. 2.48, p < 0.001) are higher in the SWA group. Rates of readmission are similar, but post-operative small bowel obstruction may be higher in the SWA group (1.3% vs. 0.35%, p = 0.06). CONCLUSION: There is a higher mean LOS and ATC in the SWA group. This study suggests that appendectomy during surgery for uncomplicated intussusception should be reconsidered and requires further investigation. TYPE OF STUDY: retrospective comparative study. LEVEL OF EVIDENCE: III.

Colorectal anastomotic leak: delay in reintervention after false-negative computed tomography scan is a reason for concern.

BACKGROUND: Early detection of anastomotic leakage (AL) after colorectal surgery followed by timely reintervention is of crucial importance. The aim of this study was to investigate the accuracy of computed tomography (CT) imaging for AL and the effects of delay in reintervention after a false-negative CT. METHODS: All files from patients who had colorectal surgery with primary anastomoses between 2009 and 2014 were reviewed. The predictive value of CT scanning for AL was determined and correlated with short-term postoperative patient outcomes. In addition, factors predictive of false-negative scans were assessed. RESULTS: Six hundred and twenty-eight patient files were reviewed. In total, a CT scan was performed in 127 patients. Overall, leakage was seen in 49 patients (7.8%). The positive and negative predictive values were 78 and 88%, respectively. Sensitivity was 73% and specificity 91%. In patients with a true-positive CT (n = 24), reintervention followed after a median interval of 0 days (IQR 1), whereas this was 1 day (IQR 2) in the false-negative group (n = 11) (p < 0.05). This was associated with a significantly increased mortality rate (1/24 = 4.2% vs 5/11 = 45.5%) (p < 0.005), an increased length of hospital stay [median 28 days (IQR 26) vs 54 days (IQR 20) (p < 0.05)]. CONCLUSIONS: Delayed reintervention after false-negative CT scanning is associated with a high mortality rate and a significant increase in length of hospital stay.

The comparison of saline enema and bisacodyl in rectal preparation before anorectal surgery.

BACKGROUND: Given the limited data on the need of mechanical bowel preparation application before anorectal surgeries and the preferred method for bowel preparation, we aimed to compare saline enema and bisacodyl in rectal preparation before anorectal surgery. MATERIALS AND METHODS: This is a randomized clinical trial study. Seventy-nine hospitalized patients for anorectal surgery (hemorrhoid, fissure, and fistula) were recruited by convenient sampling and then randomly allocated to receive 500 cc Saline by rectal enema or six bisacodyl tablets (Sobhan company) beginning from a day before the operation in order to prepare the bowel. After surgery, surgeons' satisfaction of the surgery and patients' satisfaction of the preparation process were evaluated in the ward using Likert score by a nurse blind to the study. Also, the patients were interviewed for pain after the first defecation, using numeric rating scale based on a 0-10 scores. All patients were actively followed-up after discharge for 1 mo concerning postoperative complications. The obtained data were analyzed by SPSS software (version 16), Mann-Whitney, chi-squared, and Fisher exact tests at the significant level of P < 0/0.5. RESULTS: A total of 79 patients participated in the study, 38 received 500-cc saline by rectal enema and 41 bisacodyl tablets. No significant differences were observed between the two groups in most variables except for pain after the first defecation (P = 0.032). CONCLUSIONS: According to the results, the bisacodyl approach results in less pain in the first postoperative defecation and fewer complications than the rectal enema. Thus, bisacodyl can be suggested as a superior counterpart for enema.

Intussusception clinical pathway: a survey of pediatric surgery practices.

Therapeutic reduction of intussusception by air or contrast enema may require surgery if the bowel is irreducible or perforates. There is no standard for the involvement of a pediatric surgeon in the workup of the condition. A regional survey of clinical practices was therefore undertaken to attempt to establish a consensus as to when the presence of a pediatric surgeon is required. Distributed to pediatric surgeons at 32 institutions, a questionnaire asked the process of imaging and reduction of infants with intussusception and the extent of pediatric surgical involvement. Surgeons at 29 institutions responded (91%). Ultrasound was used in diagnosis in 16 (55%), 13 (45%) requiring a positive ultrasound diagnosis of intussusception before attempting reduction. Three-fourths (22 [76%]) required surgeon notification that enema reduction was taking place, and one-fourth (seven [24%]) required prior surgical consultation. Only three (10%) required the presence of a surgery team member. Most (21 [72%]) did not demand one, and five (18%) indicated that surgical presence was desirable but not a necessity. There is no consensus for pediatric surgical involvement before and during reduction of an intussusception.

Nonopioid pharmacological management of malignant bowel obstruction: a New Zealand-wide survey.

BACKGROUND: Malignant bowel obstruction (MBO) is a common condition among palliative patients and has limited management options. There is a paucity of widely accepted national and international evidence-based guidelines to direct the management of MBO in palliative patients. OBJECTIVE: The aim of this study was to survey current practice in New Zealand of nonopioid pharmacological management of MBO and compare it with the available literature. METHODS: The study utilized a survey consisting of three scenarios: probable incomplete malignant bowel obstruction (PIMBO), incomplete malignant bowel obstruction (IMBO), and complete malignant bowel obstruction (CMBO). An online survey was conducted over 2 months targeting palliative medicine practitioners working in a hospital, hospice inpatient unit, or community setting in New Zealand. RESULTS: Forty-eight doctors responded. Of the respondents, 56.3% used guidelines to manage MBO; however, 88.9% of the guidelines used were locally generated at the doctor's institution. Metoclopramide was the drug of choice in treating PIMBO, whereas haloperidol and hyoscine butylbromide (HB) were the preferred drugs as the severity of bowel obstruction increased. Dexamethasone was accepted as standard practice for managing all severities of MBO. A variation in the preferred starting and maximum dose of all the drugs was seen. There was a decrease in the use of laxatives and enemas as the severity of MBO increased. CONCLUSION: Variation in practice for managing MBO was evident among doctors in New Zealand. There is a need for national and international evidence-based guidelines to help define best management for the differing severities of this problematic condition.

Indications for repeated enema reduction of intussusception in children.

INTRODUCTION: Intussusception is a common abdominal emergency in early childhood. It is idiopathic in more than 90% of cases with incidence of 1.5-4 per 1,000 live births. The treatment of choice is nonoperative hydrostatic or air enema reduction. OBJECTIVE: The aim of the study was to evaluate the influence of clinical presentation and symptom duration in non-operative treatment, considering the indications for delayed enema reduction and its efficacy. METHODS: From the total number of 107 patients with intusussception, aged from 2 months to 14 years (median 9 months), 102 (95%) patients with ileo-colic intussusceptions were treated initially by ultrasound guided saline enema. Records were reviewed for patients with failed initial treatment and delayed repeated enemas or operative procedure. The predictor variable included duration of presenting symptoms. RESULTS: Successful treatment by hydrostatic saline enemas had 58/102 (57%) patients. Success in reduction was greater it symptom duration was < 24 hours (54/62 cases; 87%, p < 0.001), compared with > 24 hours, (4/45 cases; 9%). Despite failed initial attempts, enema reduction was reattempted in 12 patients, with success in 7/12 (60%) patients. Children with symptom duration > 24 hours had a greater risk of requiring surgery (41/45 cases; 91%, p < 0.001), including 5 (5%) patients with ileo-ileal intussusceptions. CONCLUSION: The accuracy of ultrasound guided saline enema in intussusception reduction is high. Delay in presentation decreases success of non-operative treatment. Delayed enema reduction is important therapeutic option for intussusceptions. Surgical treatment is indicated in cases of complications.

Topical therapy is underused in patients with ulcerative colitis.

The availability of new topical preparations for the treatment of left sided ulcerative colitis offers a therapy optimization for many patients. Rectal application of steroids and 5-aminosalicylic acid (5-ASA) is associated with fewer side effects and has a higher therapeutic efficacy in left-sided colitis as compared to a systemic therapy. Therefore, we were interested in the use of topical therapy in patients with ulcerative colitis. The key question was whether topical treatment is more frequently used than oral therapy in patients with proctitis and left sided colitis. Data of 800 patients of the Swiss IBD cohort study were analyzed. Sixteen percent of patients of the cohort had proctitis, 21% proctosigmoiditis and 41% pancolitis. Topical therapy with 5-ASA or corticosteroids was given in 26% of patients with proctitis, a combined systemic and topical treatment was given in 13%, whereas systemic treatment with 5-ASA without topical treatment was given in 29%. Proportion of topical drug use decreased with respect to disease extension from 39% for proctitis to 13.1% for pancolitis (P=0.001). Patients with severe colitis received a significantly higher dose of topical 5-ASA than patients in remission. Side effects of topical or systemic 5-ASA or budesonide treatment were less frequently seen compared to other medications. Topical treatment was frequently stopped over time. The quality of life was the same in patients with limited disease compared to patients with pancolitis. Topical treatment in proctitis patients was underused in Switzerland. Since topical treatment is safe and effective it should be used to a larger extend.

Air enema reduction of intussusception: a registrar-led, protocol-driven service is safe and effective.

PURPOSE: In the UK, air enema reduction of intussusception is predominantly performed by consultant radiologists. At our institution, it is usually performed by a team involving radiology and surgical registrars. The purpose of this study was to assess who performs air enemas in the UK and the efficacy and safety of our registrar-led service. METHODS: A telephone survey of paediatric surgical centres in the UK was performed asking who performs air enema in these institutions. Following this, a retrospective review of all air enemas at our institution between January 2005 and 2011 was performed. Cases were identified from radiology databases and reviewed for grade of radiologist, perforation and outcome. RESULTS: At all 25 centres, consultant radiologists performed air enemas. At our institution 145 enemas were performed in 6 years. 141 were analysed (54 girls, 87 boys). Median age was 9 months (range 3-107 months). 82 % were performed by the registrar-only team. Over 6 years the registrar-led reduction rate was 77.5 % and in the last 3 years 84 %. The perforation rate was 0.9 %. CONCLUSION: A paediatric surgical registrar-led service for air enema reduction can be safe and effective ensuring a team approach is adopted, equipment is efficient and a strict protocol is applied.

Risk factors for surgery in pediatric intussusception in the era of pneumatic reduction.

INTRODUCTION: Surgical treatment is still necessary for intussusception management in a subgroup of patients, despite advances in enema reduction techniques. Early identification of these patients should improve outcomes. METHODS: The medical records of patients treated for intussusception at our institution from 2006 to 2011 were reviewed. Univariate and multivariate analyses, including stepwise logistic regression, were performed. RESULTS: Overall, 379 patients were treated for intussusception, and 101 (26%) patients required operative management, with 34 undergoing intestinal resection. The post-operative complication rate was 8%. On multivariate analysis, failure of initial reduction (OR 9.9,p=0.001 95% CI, 4.6-21.2), a lead point (OR 18.5,p=0.001 95% CI, 6.6-51.8) or free/interloop fluid (OR 3.3,p=0.001 95% CI, 1.6-6.7) or bowel wall thickening on ultrasound (OR 3.3,p=0.001 95% CI, 1.1-10.1), age <1 year at reduction (OR 2.7,p=0.004, 95% CI, 1.4-5.9), and abdominal symptoms>2 days (OR 2.9,p=0.003, 95% CI, 1.4-5.9) were significantly associated with a requirement for surgery. Similarly, a lead point (OR 14.5, p=0.005 95% CI, 2.3-90.9) or free/interloop fluid on ultrasound (OR 19.8, p=0.001 95% CI, 3.4-117) and fever (OR 7.2, p=0.023 95% CI, 1.1-46) were significantly associated with the need for intestinal resection. CONCLUSION: Abdominal symptoms>2 days, age<1 year, multiple ultrasound findings, and failure of initial enema reduction are significant predictors of operative treatment for intussusception. Patients with these findings should be considered for early surgical consultation or transfer to a hospital with pediatric surgical capabilities.

Variation in practice patterns and resource utilization surrounding management of intussusception at freestanding Children's Hospitals.

PURPOSE: To characterize variation in practice patterns and resource utilization associated with the management of intussusception at Children's Hospitals. METHODS: A retrospective cohort study (1/1/09-6/30/11) of 27 Children's Hospitals participating in the Pediatric Health Information System database was performed. Hospitals were compared with regard to their rates of operative management following attempted enema reduction, prophylactic antibiotic utilization, same-day discharge for those successfully managed non-operatively, 48-h readmission rates, and case-related cost and charges. RESULTS: 2544 patients were identified (median: 93 cases/center) with a median age of 17 months. The rate of operation following attempted enema reduction varied significantly across hospitals (overall rate: 21.1%: range: 11%-62.8%; p<0.0001). For patients managed non-operatively, significant variability was found for prophylactic antibiotic utilization (overall rate: 23.3%; range: 1.4%-93.2%; p<0.0001), same-day discharge (overall rate: 15.2%; range: 0%-83.8%; p<0.0001), readmission rates (overall rate: 17.5%; range: 5.3%-32.1%; p<0.0001), treatment-related costs (overall median: $2490; range: $829-$5905; p<0.0001), and charges (overall median: $6350; range: $2497-$10,306; p<0.0001). Variability in costs and charges was even greater when analyzing all patients (operative and non-operative) with intussusception (overall cost median: $2865; range: $1574-$6763; p<0.0001; overall charge median: $7110; range: $3544-$22,097; p<0.0001). CONCLUSION: Significant variation in practice patterns and resource utilization exists between Children's Hospitals in the management of intussusception. Prospective analysis of practice variation and appropriately risk-adjusted outcomes through a collaborative quality-improvement platform could accelerate the dissemination of best-practice guidelines for optimizing cost-effective care.

[Functional proctology at the University of Pécs]. / Funkcionális proktológia a Pécsi Tudományegyetemen.

INTRODUCTION: Functional proctological investigations have been introduced at Pécs University of Sciences 15 years ago. The Pelvic Floor Multidisciplinary Team has been re-launched after many years of pause in 2010. Experience of the team in the treatment of faecal incontinence and obstructed defecation syndrome is discussed. PATIENTS: In the past 3 years 9 patients underwent sphincter reconstruction for faecal incontinence. The Pelvic Floor Team in the past 1.5 year consulted 31 patients with constipation, who were considered by the referee for surgical intervention. Following investigations 10 patients underwent surgery, the rest of them were treated conservatively. Seven patients underwent perineal reconstruction with mesh, three patients had ventral rectopexy with additional levatoro-pexy. RESULTS: 78% of patients operated on for faecal incontinence reported full continence, 88% improvement. We invented a new symptom score with a maximum of 20 points to evaluate results of treatment of patients with Obstructed Defecation Syndrome. Patients who underwent perineal repair were interviewed pre and postoperatively. They scored 14 ± 2.83 and 5.4 ± 4.62 points, respectively (p = 0.0075). CONCLUSION: Functional proctological patients require a specialist approach from history taking through investigation to treatment. Majority of patients benefit from conservative treatment. Adequate patient selection is essential for successful surgical treatment. Symptom scores applied pre and postoperatively facilitate proper patient selection for various surgical methods.

Intussusception among Japanese children: an epidemiologic study using an administrative database.

BACKGROUND: The epidemiology of intussusception, including its incidence, can vary between different countries. The aim of this study was to describe the epidemiology of childhood intussusception in Japan using data from a nationwide inpatient database. METHODS: We screened the database for eligible cases ≤ 18 years of age, who were coded with a discharge diagnosis of intussusception (International Classification of Diseases, 10th revision: K-561) between July to December in 2007 and 2008. We then selected cases according to Level 1 of the diagnostic certainty criteria developed by the Brighton Collaboration Intussusception Working Group. We examined the demographics, management, and outcomes of cases, and estimated the incidence of intussusception. RESULTS: We identified 2,427 cases of intussusception. There were an estimated 2,000 cases of infantile intussusception annually in Japan, an incidence of 180-190 cases per 100,000 infants. The median age at diagnosis was 17 months, and two-thirds of the patients were male. Treatment with an enema was successful in 93.0% of cases (2255/2427). The remainder required surgery. Secondary cases accounted for 3.1% (76/2427). Median length of hospital stay was 3 days. Of the 2,427 cases, we found 2 fatal cases associated with intussusception. CONCLUSIONS: This is currently the largest survey of childhood intussusception in Asia using a standardized case definition. Our results provide an estimate of the baseline risk of intussusception in Japan, and it is higher than the risk observed in other countries.

Adherence to follow-up after a positive fecal occult blood test in an organized colorectal cancer screening program in Korea, 2004-2008.

BACKGROUND AND AIM: To investigate the participation rates, positivity rates, and follow-up rates from 2004 to 2008 in an organized colorectal cancer (CRC) screening program using a fecal occult blood test (FOBT) in Korea. METHODS: The study population was men and women aged 50 years or older who were invited to participate in the National Cancer Screening Program for CRC between 1 January 2004 and 31 December 2008. We collected the FOBT results and follow-up information for the FOBT positives. RESULTS: Participation rates increased steadily each year from 10.5% in 2004 to 21.1% in 2008. Between 2004 and 2008, FOBT positivity rates declined from 8.0% to 6.8%. Among the FOBT-positives, 61.3% of participants underwent either colonoscopy or double contrast barium enema (DCBE) in 2004, and this rate decreased to 38.6% in 2008. Age, health insurance type, and screening history were associated with adherence to follow-up test after a positive FOBT. With regard to follow-up tests, colonoscopy rates increased from 17.9% in 2004 to 27.6% in 2008, while DCBE decreased from 43.4% in 2004 to 11.0% in 2008. Colonoscopy was significantly more likely to be chosen as a follow-up test by men, participants aged 50-59 years, and National Health Insurance beneficiaries. CONCLUSION: These findings suggest that targeting participants for follow-up, based on age and previous screening history, could be a good way to improve the follow-up rate.

Preoperative bowel preparation in gynecologic oncology: a review of practice patterns and an impetus to change.

OBJECTIVES: Preoperative mechanical bowel preparation (MBP) is commonly used in gynecologic oncology (GO). We wished to assess the practice patterns and beliefs within the Society of Gynecologic Oncologists of Canada (GOC), review the literature on MBP as applicable to GO surgeries, and construct recommendations specific to our subspecialty. METHODS: A 23-question, 10-minute Internet survey was sent to 110 GOC members regarding their use, rationale, and understanding of the literature pertaining to MBP for GO surgeries. The historical justifications for using MBP before pelvic and abdominal surgery were identified through literature review. RESULTS: Half of respondents (48%) routinely order MBP despite acknowledgment in 77% that there was no good evidence to support its use. Use encompassed all cancer sites (53% ovary, 32% endometrial, 27% cervical, and 8% vulvar) and approaches (43% laparotomy and 29% laparoscopy/robotics). The most common reasons cited for ordering MBP were to decrease risk of anastomotic leak and improve visualization. In the last 5 years, use of MBP has decreased in most (77%) GOC respondents. Of all respondents, 71% felt that formal recommendations specific to the field of GO would be helpful. None of the arguments for using MBP could be justified in the literature. In contrast, common and often serious sequelae from MBP are frequently described. Admitted use of bowel preparation in other surgical specialties was even higher (53%-99%) than within the GOC. CONCLUSIONS: There is no literature to support the routine use of MBP in GO. Published recommendations (herein) should support and guide change in practice.

Validity of self-reported colorectal cancer test use in different racial/ethnic groups.

OBJECTIVE: Prevalence of colorectal cancer (CRC) screening is ascertained by self-reported screening, yet little is known about the accuracy of this method across different racial/ethnic groups, particularly Hispanics. The purpose of this study was to compare the accuracy of CRC self-report measures across three racial/ethnic groups. METHODS: During 2004 and 2005, 271 white, African-American and Hispanic participants were recruited from a primary care clinic in Southeast Texas, and their CRC testing history based on self-report and medical record (the 'gold standard') were compared. RESULTS: Over-reporting was prevalent. Overall, up-to-date CRC test use was 57.6% by self-report and 43.9% by medical record. Racial/ethnic group differences were most pronounced for Hispanics in whom sensitivity was significantly lower for any up-to-date testing, fecal occult blood testing, flexible sigmoidoscopy and double contrast barium enema. There were no statistically significant differences across groups for over-reporting, specificity or concordance. CONCLUSIONS: Self-report prevalence data are overestimating CRC test use in all groups; current measures are less sensitive in Hispanics.

Long-term follow-up of patients after antegrade continence enema procedure.

BACKGROUND: Antegrade continence enema (ACE) has become an important therapeutic modality in the treatment of intractable constipation and fecal incontinence. There are little data available on the long-term performance of the ACE procedure in children. METHODS: A retrospective review of patients who underwent the ACE procedure was conducted. Irrigation characteristics and complications were noted. Outcome was assessed for individual encounters based on frequency of bowel movements, incontinence, pain, and predictability. RESULTS: One hundred seventeen patients underwent an ACE. One hundred five patients had at least 6 months of follow-up, and were included in the analysis. Diagnoses included myelodysplasia (39%), functional intractable constipation (26%), anorectal malformations (21%), nonrelaxing internal anal sphincter (7%), cerebral palsy (3%), and other diagnoses (4%). The average follow-up was 68 months (range 7-178 months). At the last follow-up, 69% of patients had successful bowel management. Of the 31% of patients who did not have successful bowel management, 20% were using the ACE despite suboptimal results, 10% required surgical removal, and 2% were not using the ACE because of behavioral opposition to it. Patients were started on normal saline, but were switched to GoLYTELY (PEG-3350 and electrolyte solution) if there was an inadequate response (61% at final encounter). Additives were needed in 34% of patients. The average irrigation dose was 23 ± 0.7 mL/kg. The average toilet sitting time was 51.7 ± 3.5 minutes, with infusions running for 12.1 ± 1.2 minutes. Stomal complications occurred in 63% (infection, leakage, and stenosis) of patients, 33% required surgical revision and 6% eventually required diverting ostomies. CONCLUSIONS: Long-term use of the ACE gives successful results in 69% of patients, whereas 63% had a stoma-related complication and 33% required surgical revision of the stoma.

Lack of follow-up after fecal occult blood testing in older adults: inappropriate screening or failure to follow up?

BACKGROUND: It is unclear whether lack of follow-up after screening fecal occult blood testing (FOBT) in older adults is due to screening patients whose comorbidity or preferences do not permit follow-up vs failure to complete follow-up in healthy patients. METHODS: A prospective cohort study of 2410 patients 70 years or older screened with FOBT was conducted at 4 Veteran Affairs (VA) medical centers from January 1 to December 31, 2001. The main outcome measure was receipt of follow-up within 1 year of FOBT based on national VA and Medicare data. For patients with positive FOBT results, age and Charlson comorbidity scores were evaluated as potential predictors of receiving a complete colon evaluation (colonoscopy or sigmoidoscopy plus barium enema), and medical records were reviewed to determine reasons for lack of follow-up. RESULTS: A total of 212 patients (9%) had positive FOBT results; 42% received a complete colon evaluation within 1 year. Age and comorbidity were not associated with receipt of a complete follow-up, which was similar among patients 70 to 74 years old with a Charlson score of 0 compared with patients 80 years or older with a Charlson score of 1 or higher (48% vs 41%; P=.28). The VA site, number of positive FOBT cards, and number of VA outpatient visits were predictors. Of 122 patients who did not receive a complete follow-up within 1 year, 38% had documentation that comorbidity or preferences did not permit follow-up, and over the next 5 years 76% never received a complete follow-up. CONCLUSIONS: While follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of follow-up. Efforts to improve follow-up should address the full chain of decision making, including decisions to screen and decisions to follow up.