National Landscape of Unplanned 30-Day Readmission Rates for Acute Non-hemorrhagic Diverticulitis: Insight from National Readmission Database.

BACKGROUND: Early readmissions are an important indicator of the quality of care. Limited data exist describing hospital readmissions in acute diverticulitis. The study aimed to describe unplanned, 30-day readmissions among adult acute diverticulitis patients and to assess readmission predictors. METHODS: We analyzed the 2013 and 2014 United States National Readmission Database and identified acute diverticulitis admissions using administrative codes in adult patients older than 18 years of age. Our primary outcome was a 30-day, unplanned readmission rate. We used Chi-square tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals for associations with readmissions adjusting for confounders. RESULTS: In the cohort of 364,511 hospitalizations with acute diverticulitis, as the primary diagnosis on index admission, 31,420 (8.6%) had at least one unplanned 30-day readmission. Sixty percent of the readmissions occurred within the first 2 weeks of the index admission. The most common reasons for unplanned 30-day readmission were due to diverticulitis of the colon (41.5%), postoperative infection (4.2%), septicemia (3.6%), intestinal infection due to Clostridium difficile (3%), and other digestive system complications such bleeding or fistula (2.8%). Multivariable analysis showed advance age (> 75 years), discharge against medical advice, comorbidities (renal failure, coronary artery disease, atrial fibrillation, congestive heart failure, hypertension, diabetes, obesity, weight loss, chronic lung disease, malignancy), blood transfusion, Medicare and Medicaid insurance, and increased length of stay (> 3 days) were associated with significantly higher odds for readmission. Patients who have undergone abdominal surgery during index admission were 31% less likely to get readmitted. CONCLUSIONS: On a national level, 1 in 11 hospitalizations for acute diverticulitis was followed by unplanned readmission within 30 days with most admissions occurring in the first 2 weeks. Multiple modifiable and non-modifiable factors influencing readmission rates were noted. Further studies should examine if strategies that address these predictors can decrease readmissions.

Associations of a Preoperative Anemia and Suboptimal Iron Stores Screening and Management Clinic in Colorectal Surgery With Hospital Cost, Reimbursement, and Length of Stay: A Net Cost Analysis.

BACKGROUND: In 2016, a preoperative clinic was implemented to screen, evaluate, and manage anemia and suboptimal iron stores at a major tertiary care medical center in Western Australia. Few studies compare the costs and reimbursements associated with preoperative anemia and suboptimal iron stores management. The objective of our study was to conduct a net cost analysis associated with the implementation of this clinic. METHODS: We designed a retrospective cohort study involving elective colorectal surgical admissions over a 3-year period. The baseline year selected was the 2015-2016 financial year, with outcomes in the 2016-2017 and 2017-2018 year compared to baseline. The study perspective was the Western Australian Health System. Hospital costs were extracted from the health service clinical costing system, which captures costs at the admission level. The primary outcome was net cost, defined as gross cost minus reimbursement (or funding) received. RESULTS: Our 3-year study included 544 admissions for elective colorectal surgery. After the implementation of the preoperative clinic, 73.4% (n = 257) of admissions were screened for anemia and suboptimal iron stores, and 31.4% (n = 110) received intravenous iron. In our adjusted analysis, when comparing the final year (2017-2018) with baseline (2015-2016), the units of red blood cells transfused per admission decreased 53% (142 vs 303 units per 1000 discharges; P = .006), and mean hospital length of stay decreased 15% (7.7 vs 9.1 days; P = .008). When comparing the final year with baseline, rectal resection admissions were associated with a mean decrease in the net cost of Australian dollar (A$) 7619 (95% confidence interval, 4230-11,008; P < .001) between 2015-2016 and 2017-2018. For small and large bowel procedures, there was a mean decrease of A$6744 (95% confidence interval, 2430-11,057; P = .002). CONCLUSIONS: The implementation of a preoperative anemia and suboptimal iron stores screening and management clinic in elective colorectal surgery was associated with reductions in red cell transfusions, length of stay, and net costs.

Treating pediatric colorectal patients in low and middle income settings: Creative adaptation to the resources available.

Colorectal disease profiles for children in low- and middle-income settings (LMIC) are characterized by late presentation, increased complications and limited follow-up in many cases. There is a high prevalence of infectious conditions causing secondary colorectal disease such as Mycobacterium Tuberculosis(TB), Human Immunodeficiency Virus(HIV) and Human Papilloma Virus(HPV), which also impact the management of other primary colorectal conditions, such as wound-healing and intestinal anastomosis. Perineal trauma from sexual assault, motor vehicle or pedestrian accidents, burns, and traditional enemas are commonly encountered and may require adaptation of principles used in treatment of congenital anomalies such as Hirschsprung's disease and Anorectal Malformations for reconstruction. Endemic conditions in certain LMIC require further research to delineate underlying causes and optimize management, such as "African" degenerative visceral leiomyopathy, congenital pouch colon in the Indian subcontinent, and congenital H-type rectal fistulae prevalent in Asia. These unique disease profiles require creative adaptations of resources within poor healthcare infrastructure settings. These special challenges and pitfalls in colorectal care and complications of adverse socioeconomic conditions, are discussed.

Adult intussusception : A 14-year retrospective study of clinical assessment and computed tomography diagnosis.

BACKGROUND AND STUDY AIMS: Intussusception in adults often remains unrecognized. Our aim was to report our experience with this entity to determine the usefulness of CT scan in its preoperative diagnosis. PATIENTS AND METHODS: The medical records and imaging studies of all patients ≥16 years of age with intussusception, who were managed at our hospitals, were retrospectively reviewed. RESULTS: 17 cases of adult intussusception (7 males, 10 females; mean age 35.9 years; age range of 16-78) were identified. The diagnosis was possible in all patients using CT scan. The underlying etiologies were colon cancer (n=2), lymphoma (n=2), small bowel polyps (n=2), jejunal lipoma (n=1), metastatic melanoma (n=1), Meckel's diverticulum (MD) (n=1) and idiopathic (n=1). In the remaining 7 patients, the intussusceptions were of the transitory form and were treated conservatively and no significant sequela occurred after a follow-up of 2-60 months. CT scan findings in transient cases characteristically showed that the intussusception was localized to the proximal intestine and all of them had a short segment (2-4 cm) of intussusception. CONCLUSIONS: The important role of the CT in the preoperative diagnosis of intussusception and characterizing its causes cannot be overemphasized. All transient cases had a short segment of intussusception.

Application of NICE guideline NG12 to the initial assessment of patients with lower gastrointestinal symptoms: not FIT for purpose?

Background The National Institute for Health and Care Excellence (NICE) published NG12 in 2015. The referral criteria for suspected colorectal cancer (CRC) caused controversy, because tests for occult blood in faeces were recommended. Faecal immunochemical tests for haemoglobin (FIT), which estimate faecal haemoglobin concentrations (f-Hb), might more than fulfil the intentions. Our aim was to compare the utility of f-Hb as the initial investigation with the NICE NG12 symptom-based guidelines. Methods Data from three studies were included. Patients had sex, age, symptoms, f-Hb and colonoscopy and histology data recorded. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV) of f-Hb and NG12 were calculated for all significant colorectal disease (SCD: CRC, higher risk adenoma and inflammatory bowel disease). Overall diagnostic accuracy was also estimated by the area under the receiver operating characteristic curve (AUC). Results A total of 1514 patients were included. At a cut-off of ≥10 µg Hb/g faeces, the sensitivity of f-Hb for CRC was 93.3% (95% confidence interval (CI): 80.7-98.3) with NPV of 99.7% (95%CI: 99.2-99.9). The sensitivity and NPV for SCD were 63.2% (95%CI: 56.6-69.4) and 96.0% (95%CI: 91.4-94.4), respectively. The NG12 sensitivity and NPV for SCD were 58.4% (95%CI: 51.8-64.8) and 87.6% (95%CI: 85.0-89.8), respectively. The AUC for CRC was 0.85 (95% CI: 0.87-0.90) for f-Hb versus 0.65 (95%CI: 0.58-0.73) for NG12 ( P < 0.005). For SCD, the AUC was 0.73 (95%CI: 0.69-0.77) for f-Hb versus 0.56 (95%CI: 0.52-0.60) for NG12 ( P < 0.0005). Conclusion f-Hb provides a good rule-out test for SCD and has significantly higher overall diagnostic accuracy than NG12.

The Drivers of Discretionary Utilization: Clinical History Versus Physician Supply.

PURPOSE: Because the effect of physician supply on utilization remains controversial, literature based on non-Medicare populations is sparse, and a physician supply expansion is under way, the potential for physician-induced demand across diverse populations is important to understand. A substantial proportion of gastrointestinal endoscopies may be inappropriate. The authors analyzed the impact of physician supply, practice patterns, and clinical history on esophagogastroduodenoscopy (EGD, defined as discretionary) among patients hospitalized with lower gastrointestinal bleeding (LGIB). METHOD: Among 34,344 patients hospitalized for LGIB from 2004 to 2009, 43.1% and 21.3% had a colonoscopy or EGD, respectively, during the index hospitalization or within 6 months after. Linking to the Dartmouth Atlas via patients' hospital referral region, gastroenterologist density and hospital care intensity (HCI) index were ascertained. Adjusting for age, gender, comorbidities, and race/education indicators, the association of gastroenterologist density, HCI index, and history of upper gastrointestinal disease with EGD was estimated using logistic regression. RESULTS: EGD was not associated with gastroenterologist density or HCI index, but was associated with a history of upper gastrointestinal disease (OR 2.30; 95% CI 2.17-2.43), peptic ulcer disease (OR 4.82; 95% CI 4.26-5.45), and liver disease (OR 1.34; 95% CI 1.18-1.54). CONCLUSIONS: Among patients hospitalized with LGIB, large variation in gastroenterologist density did not predict EGD, but relevant clinical history did, with association strengths commensurate with risk for upper gastrointestinal bleeding. In the scenario studied, no evidence was found that specialty physician supply increases will result in more discretionary care within commercially insured populations.

Prevalence, causes and management outcome of intestinal obstruction in Adama Hospital, Ethiopia.

BACKGROUND: In Africa, acute intestinal obstruction accounts for a great proportion of morbidity and mortality. Ethiopia is one of the countries where intestinal obstruction is a major cause of morbidity and mortality. This study aims to determine prevalence, causes and management outcome of intestinal obstruction in Adama Hospital in Oromia region, Ethiopia. METHOD: A hospital based cross-sectional study design was used. Data covering the past three years were collected from hospital medical records of sampled patients. The collected data were checked for any inconsistency, coded and entered into SPSS version 16.0 for data processing and analysis. Descriptive and logistic regression analyses were used. Statistical significance was based on confidence interval (CI) of 95 % at a p-value of < 0.05. RESULT: 262 patients were admitted with intestinal obstruction. The prevalence of intestinal obstruction was 21.8 % and 4.8 % among patients admitted for acute abdomen surgery and total surgical admissions, respectively. The mortality rate was 2.5 % (6 of 262). The most common cause of small bowel obstruction was intussusceptions in 48 patients (30.9 %), followed by small bowel volvulus in 47 patients (30.3 %). Large bowel obstruction was caused by sigmoid volvulus in 60 patients (69.0 %) followed by colonic tumor in 12 patients (13.8 %). After controlling for possible confounding factors, the major predictors of management outcome of intestinal obstruction were: duration of illness before surgical intervention (adjusted odds ratio (AOR) = 0.49, 95 % CI: 0.25-0.97); intra-operative findings [Viable small bowel volvulus (SBV) (AOR = 0.08, 95 % CI: 0.01-0.95) and viable (AOR = 0.17, 95 % CI: 0.03-0.88)]; completion of intra-operative procedures (bowel resection & anastomosis (AOR = 3.05, 95 % CI: 1.04-8.94); and length of hospital stay (AOR = 0.05, 95 % CI: 0.01-0.16). CONCLUSION: Small bowel obstruction was more prevalent than large bowel obstruction. Intussusceptions and sigmoid volvulus were the leading causes of small and large bowel obstruction. Laparotomy was the most common methods of intestinal obstruction management. Bowel resection and anastomosis was the commonest intra-operative procedure done and is associated with postoperative complications. Wound infection in the affected area should be improved because it is the most common postoperative complication. This can be decreased by appropriate surgical technique and wound care with sterile techniques.

Capnographic Monitoring of Moderate Sedation During Low-Risk Screening Colonoscopy Does Not Improve Safety or Patient Satisfaction: A Prospective Cohort Study.

OBJECTIVES: Appropriate monitoring during sedation has been recognized as vital to patient safety in procedures outside of the operating room. Capnography can identify hypoventilation prior to hypoxemia; however, it is not clear whether the addition of capnography improves safety or is cost effective during routine colonoscopy, a high volume, low-risk procedure. Our aim was to evaluate the value of EtCO2 monitoring during colonoscopy with moderate sedation. METHODS: We conducted a prospective study of sedation safety and patient satisfaction before and after the introduction of EtCO2 monitoring during outpatient colonoscopy with midazolam and fentanyl using the validated PROcedural Sedation Assessment Survey (PROSAS). Complications of sedation and PROSAS scores were compared among colonoscopies with and without capnography. RESULTS: A total of 966 patients participated in our study, 465 in the pre-EtCO2 group and 501 in the EtCO2 group. On multivariate analysis, patients and nurses reported higher levels of procedural discomfort after adoption of capnography (1.71 vs. 1.00, P<0.001). No serious adverse events were seen, and minor sedation-related adverse events occurred with similar frequency in both groups (8.2% pre-EtCO2 vs. 11.2% EtCO2, P=0.115). The cost of implementing EtCO2 in our unit was $40,169.95 and added $11.68 per case. CONCLUSIONS: Colonoscopy with moderate sedation is a low-risk procedure, and the addition of EtCO2 did not improve safety or patient satisfaction but did increase cost. These data suggest that routine capnography in this setting may not be cost effective and that EtCO2 might be reserved for patients at higher risk of adverse events.

Tandem vaginoscopy with colonoscopy: a diagnostic technique for the assessment of colovaginal fistula.

AIM: Colovaginal fistula (CVF) has a negative impact on quality of life. Identifying the fistula track is a critical step in its management. In a subset of patients, localizing the fistula preoperatively can be difficult. The purpose of this report is to describe the technique and results of tandem vaginoscopy with colonoscopy (TVC). METHOD: A retrospective analysis was conducted of all patients referred to a tertiary centre with symptoms suggestive of CVF but no prior successful localization of a fistula. TVC was performed by one colorectal surgeon in the endoscopy suite under intravenous sedation. RESULTS: Between 2003 and 2013, 18 patients (median age 58 years) underwent TVC. CVF was ruled out in three patients. In the remaining 15 patients, TVC documented the fistula in 13. In eight cases a wire was passed through the fistulous track from the vagina to the colon, in three the track was large enough to be traversed with the endoscope and in two a fistulous opening was noted on the vaginal side but passage of a wire to localize the opening on the colonic side was not possible due to extensive scarring. No TVC-related complications were recorded. The sensitivity, specificity, positive predictive value and negative predictive value for TVC in detecting CVF were 86.7%, 100%, 100% and 60%, respectively. CONCLUSION: TVC is a useful technique that can localize the fistulous track in most patients with CVF.

DIAGNOSTIC CRITERIA AND ASSESSMENT OF THE FUNCTIONAL CONDITION OF THE COLON IN PATIENTS WITH CHRONIC CONSTIPATION.

THE PURPOSE OF THE STUDY: To determine methods of functional diagnostics of disorders of motor-evacuation properties of the colon, to study motor activity with involvement in the pathological process of certain segments. MATERIALS AND METHODS: The basis of our work comes from the experience of a survey of 389 patients with chronic constipation for congenital anomalies of the colon. On the basis of the results proposed to be chronic constipation. Cologny and laparoscopic. Application of the proposed methods allowed us to completely eliminate radiation load for the patient. Methods are simple, require' no special costs are paid by the patient. RESULTS: Presents functional methods of examination of the colon depending on the type constipation. To evaluate the functional state of the terminal segments of the colon can be based on the following parameters: and propulsive peristaltic activity, reservoir function of the rectum, the condition of the switching apparatus, the possibility of evacuation of feces. CONCLUSION: In each case needs to be clarified diagnostics of the functional condition of the colon when anomalies of its development. Our methods are allowed to individualize the approach to the choice of medical tactics depending on the type of chronic a constipation and convenient in the analysis of remote results of treatment.

Rectal bleeding and implications for surgical care in Nepal.

BACKGROUND: Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world's population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries such as Nepal. The aim of this study was to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region. METHODS: A countrywide survey using the Surgeons OverSeas Assessment of Surgical Need tool was administered from May 25-June 12, 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population. In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology. Individuals were interviewed to determine the period and point prevalence of rectal bleeding and patterns of health-seeking behavior related to surgical care for this problem. Individuals aged >18 y were included in this analysis. RESULTS: A total of 1350 households and 2695 individuals were surveyed with a 97% response rate. Thirty-eight individuals (55% male) of the 1941 individuals ≥ 18 y stated they had experienced rectal bleeding (2.0%, 95% confidence interval 1.4%-2.7%), with a mean age of 45.5 (standard deviation 2.2). Of these 38 individuals, 30 stated they currently experience rectal bleeding. Health Care was sought in 18 participants with current rectal bleeding, with two major procedures performed, one an operation for an anal fistula. For those who sought health care but did not receive surgical care, reasons included no need (4), not available (6), fear and/or no trust (5), and no money for health care (1). For those with current rectal bleeding who did not seek health care, reasons included no need (1), not available (2), fear and/or no trust (6), and no money for health care (3). Twenty-three individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% confidence interval 0.8%-1.8%). CONCLUSIONS: The Nepal health care system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding. Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a health care professional and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer. Further advocacy for preventative medicine and easier access to surgical care in lower-income countries is crucial to avoid emergency surgeries, advanced stage malignancies, or fatalities from treatable conditions.

Prospective survey of veterinary practitioners' primary assessment of equine colic: clinical features, diagnoses, and treatment of 120 cases of large colon impaction.

BACKGROUND: Large colon impactions are a common cause of colic in the horse. There are no scientific reports on the clinical presentation, diagnostic tests and treatments used in first opinion practice for large colon impaction cases. The aim of this study was to describe the presentation, diagnostic approach and treatment at the primary assessment of horses with large colon impactions. METHODS: Data were collected prospectively from veterinary practitioners on the primary assessment of equine colic cases over a 12 month period. Inclusion criteria were a diagnosis of primary large colon impaction and positive findings on rectal examination. Data recorded for each case included history, signalment, clinical and diagnostic findings, treatment on primary assessment and final case outcome. Case outcomes were categorised into three groups: simple medical (resolved with single treatment), complicated medical (resolved with multiple medical treatments) and critical (required surgery, were euthanased or died). Univariable analysis using one-way ANOVA and Tukey's post-hoc test, Kruskal Wallis with Dunn's post-hoc test and Chi squared analysis were used to compare between different outcome categories. RESULTS: 1032 colic cases were submitted by veterinary practitioners: 120 cases met the inclusion criteria for large colon impaction. Fifty three percent of cases were categorised as simple medical, 36.6% as complicated medical, and 9.2% as critical. Most cases (42.1%) occurred during the winter. Fifty nine percent of horses had had a recent change in management, 43% of horses were not ridden, and 12.5% had a recent / current musculoskeletal injury. Mean heart rate was 43 bpm (range 26-88) and most cases showed mild signs of pain (67.5%) and reduced gut sounds (76%). Heart rate was significantly increased and gut sounds significantly decreased in critical compared to simple medical cases (p<0.05). Fifty different treatment combinations were used, with NSAIDs (93%) and oral fluids (71%) being administered most often. CONCLUSIONS: Large colon impactions typically presented with mild signs of colic; heart rate and gut sounds were the most useful parameters to distinguish between simple and critical cases at the primary assessment. The findings of seasonal incidence and associated management factors are consistent with other studies. Veterinary practitioners currently use a wide range of different treatment combinations for large colon impactions.

[Endoscopic assessment of large bowel and safety of bowel preparation and sedoanalgesia in patients with advanced liver cirrhosis]. / Ocena endoskopowa jelita grubego oraz bezpieczenstwo przygotowania jelita i sedoanalgezji u chorych z zaawansowana marskoscia watroby.

INTRODUCTION: In patients with advanced liver cirrhosis endoscopic images of large bowel are still poorly recognized in comparison with upper digestive tract. At present, the colonoscopy is examination routinely performed during qualification to liver transplantation. The purpose of this study was to retrospectively analyze colonoscopic reports and to assess a safety of all procedures realized before and during colonoscopy. MATERIAL AND METHODS: The study included 46 patients with liver cirrhosis (males 54.4%, females 45.6%) at age of 18-66 years, hospitalized between 2007-2009 for qualification to liver transplantation. Colonoscopy was done in short general sedation, and standard bowel preparation involved 256 g of polyethylene glycol dissolved in 4 liters of fluid given to the patient one day before colonoscopy. RESULTS: In 26.1% of patients no pathology was found on colonoscopy. Anal/rectal varices were found in 41.3% of patients, lesions classified as portal colopathy in 13% of patients and sigmoid diverticula in 8.7% of patients. In 17 (37%) of patients colonoscopy disclosed 46 polyps in large bowel (38 polyps in 12 patients were retrieved for histopathological examination). In 4 (8.7%) patients polyps were hyperplastic, in 6 (about 13%) tubular adenomas of low grade dysplasia and in 2 (4.35%) tubulo-villous adenomas of low grade dysplasia. Tubulo-villous adenomas were found only in patients with alcoholic cirrhosis. Colonoscopy did not worsen the general clinical state of any patient, however, as compared with compensated cirrhotics, the patients with ascites and/or peripheral edema showed features of water retention (larger body mass changes -0.50 +1.21 kg vs 0.23 +1.38 kg; p < 0.05). After colonoscopy a significant increase of body temperature by 0.23 +0.30 degrees C; p < 0.001 was noted, while examination had no significant effect on serum creatinine level and white blood cell number. CONCLUSIONS: Liver cirrhosis may predispose to certain diseases of the large bowel, including portal colopathy and adenomatous polyps. Procedures accomplished before and during colonoscopy seem to be safe for cirrhotic patients, however, in decompensated cirrhosis exists a tendency to further water retention.

[Diagnostic performance of colonoscopy in lower gastrointestinal bleeding]. / Rendimiento de la colonoscopia en la hemorragia digestiva baja.

Lower gastrointestinal bleeding is a common medical emergency that usually has a favorable prognosis. However, these events generate high resource use. The procedure of choice is colonoscopy with prior colonic preparation due to its high diagnostic performance and safety and the possibility of endoscopic therapy. Emergency colonoscopy has advantages over elective colonoscopy, showing higher diagnostic yield and superior detection of stigmata of recent bleeding, increasing the probability of endoscopic treatment. Predictive models of bleeding severity and recurrence have been published, allowing resource use to be rationalized, mainly by reducing hospital stay in low-risk patients. Nevertheless, the optimal timing of emergency colonoscopy has not been established and the impact of endoscopic treatment on prognosis is controversial.

Assessment of predictors of mortality and severity in patients with colorectal perforation.

Colorectal perforation is a life-threatening disease with high mortality and morbidity. The correct and prompt diagnosis and accurate judgment of severity are necessary. We retrospectively investigated 30 patients with colorectal perforation to assess predictors of mortality and severity, and evaluated the usefulness of computed tomography (CT) for the initial diagnosis. The severity of peritonitis was assessed using clinical factors and Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) scores. Abdominal free air was detected by CT in 92% of patients with colorectal perforation, whereas only 36.6% showed evidence of abdominal free air by conventional radiography. The perforation site was correctly diagnosed in 14 of 25 cases (56%). Overall mortality was 16.7%. Survivors were younger than nonsurvivors, and POSSUM physiological and mortality scores were significantly lower for survivors compared with nonsurvivors. The amount of intraperitoneal soiling by large bowel content determined disease severity in terms of the need for postoperative respiratory management. In conclusion, CT is necessary for precise diagnosis, and the POSSUM score is helpful for the evaluation of disease mortality and severity.

Capsule endoscopy: no longer limited to the small bowel.

Capsule endoscopy is the latest evolution in gastrointestinal endoscopy and the first to enable complete investigation of the small bowel. Recent new developments in the field of capsule endoscopy include the esophageal capsule (Pilcam ESO) and the colonic capsule (PillCam Colon). esophageal and colonic capsules have two heads with two lenses and cameras. The new capsules have the capability of taking more frames from both sides. The indications for the esophageal capsule examination are diagnosis and follow-up of Barrett's esophagus and esophageal varices. The colonic capsule can be used for colorectal cancer screening and for incomplete colonoscopy. Regarding other new technologies, continuous quality control is needed for the performance, appropriateness of the indications, diagnostic yield, procedure-specific outcome assessment, and cost-effectiveness.

Improving colonoscopy quality through health-care payment reform.

Problems with the quality of colonoscopy are well recognized. Variation in colonoscopist performance is compounded by payment structures that reward volume rather than quality. Payment reform has emerged as one strategy to address these and more systemic problems in the quality of health care. Various forms of value-based purchasing might encourage a realignment of incentives, and allow reimbursement to be directly linked with clinically important goals of colonoscopy. This paper proposes criteria for the selection of quality measures, and three candidate indicators to define quality for the purpose of payment reform in colonoscopy: cecal intubation rate, adenoma detection rate, and recommended post-polypectomy surveillance interval. These measures represent valid, credible, and reliable indicators of the quality of colonoscopy for colorectal cancer screening and surveillance. Payment reform should explicitly link public reporting and performance on these quality measures to payment for colonoscopy.