Proposed clinical operative synoptic report for ileocolic resection for Crohn's disease.

ABSTRACT

BACKGROUND: Crohn's disease patients may require multiple surgeries during their lifetime. Because operative reports are not standardized, information relevant to future management may not be documented. Synoptic reports used in other fields such as histopathology have proven to be effective and allow consistent documentation of results. The aim of this study was to retrospectively review the completeness of the operative reports for ileocolic Crohn's resections (ICR) and to propose a synoptic report. METHODS: A draft synoptic operative report for ICR for Crohn's disease was presented in the IBD multidisciplinary meeting and a Delphi process used to gain consensus for inclusion in the synoptic report. Retrospective analysis of consecutive ICR from January 2010 to April 2023 was undertaken to determine the presence of the standardized criteria. RESULTS: A total of 66 ICR were performed in 63 patients during the study period. No operation reports were excluded. The examination of bowel for macroscopic disease was partially documented in 88% cases. The extent of mesenteric resection and any difficulty encountered during dissection were poorly documented. The remaining length of small and large intestines was not documented in most operative reports. The clinical sections that were compulsory entrance in the electronic operative report achieved 100% compliance. CONCLUSION: This study has demonstrated that key information was often deficient in the operative report. This may have a significant impact on the future management of Crohn's patients and affects the interpretation of research outcomes. A proposed clinical synoptic operative report is easy to use and ensures compliance.