Improving the management and outcomes of complex non-pedunculated colorectal polyps at a regional hospital in British Columbia.

BACKGROUND: Colorectal cancer arises from precancerous lesions, primarily adenomatous and serrated polyps. Some polyps pose significant technical endoscopic challenges due to their size, location, and/or morphology. A standardized protocol for documentation and management of these polyps can optimize clinical outcomes. METHODS: A Quality Improvement project compared patients with a complex polyp (non-pedunculated, > 2 cm), for 12 months prior and 12 months after protocol introduction. Documentation and polyp management details were compared pre- and post-implementation using the Chi-square test. RESULTS: 69 patients were diagnosed with complex polyps prior to the protocol introduction and 72 after. 79% (112/141) of patients underwent endoscopic mucosal resections (EMR) locally, and 14.9% (21/141) underwent surgery locally. After protocol introduction, there was significant improvement in documentation of suspicious appearing polyps (21.7% to 47.2%, P = 0.001), luminal circumference (14.5% to 34.7%, P = 0.005), and management plans (87.0% to 97.2%, P = 0.023); other elements of documentation were similar. The number of patients reviewed at multidisciplinary conference (MDC) increased from 1 to 61% (P < 0.005). Patients rebooked in a 1 h endoscopy time slot increased from 19 to 58% (P < 0.005), as did specific consent for EMR from 22 to 57% (P < 0.005). Among patients with polyps 3 cm or greater (23 pre, 36 post), MDC review increased from 4 to 67% (P < 0.005), primary polypectomy decreased from 72 to 23% (P = 0.001), patients rebooked in a double endoscopy slot increased from 33 to 75% (P = 0.005), and specific consent increased from 39 to 75% (P = 0.014). There were less polyp recurrences (12/42 pre and 1/50 post) among the post-protocol cohort (P < 0.001). CONCLUSIONS: The introduction of a formalized protocol for complex polyp adjudication and management has led to improved documentation, multidisciplinary discussion, and optimal complex polyp management with dedicated time for EMR, particularly for polyps over 3 cm. There is room for improvement, and this can be approached in a collaborative manner.

Laparoscopic cholecystectomy for symptoms of biliary colic in the absence of gallstones.

BACKGROUND: Acalculous cholecystitis is a controversial entity that accounts for 5% to 22% of cholecystectomies in some series. Multiple attempts have been made to find an objective clinical algorithm for diagnosis; however, we postulate that careful evaluation of clinical presentation is adequate to allow accurate diagnosis without reliance on ancillary tests, such as cholecystokinin-stimulated scintigraphy studies. METHODS: A retrospective chart review was made of all patients who underwent laparoscopic cholecystectomy at Cariboo Memorial Hospital between April 1997 and September 2001. Patients with history and physical examination consistent with biliary colic/cholecystitis, with negative ultrasonography scans, were reviewed and a telephone survey was conducted to determine subjective clinical outcomes. RESULTS: Eighty-eight patients were eligible for the study. Age range was 19 to 78 years. Eighty-three percent were female and 17% were male. Seventy-eight percent of patients had chronic symptoms, 17% acute, and 5% acute on chronic. Pathology reports indicated that 92% of gallbladders revealed disease and 8% were reported as normal. Two percent of patients had major complications postoperatively and 9% had minor complications. No deaths had occurred. Seventy-eight percent of procedures were performed as day surgeries, with an average hospital stay of 1.3 days. Mean follow-up was 25 months, with a range of 3 to 55 months. Ninety-one percent of patients were available for telephone survey follow-up. Forty-one percent of patients reported being "very satisfied" with the outcome of their surgery, 52% were "satisfied," and 4% were "not satisfied." CONCLUSIONS: Acalculous cholecystitis is an entity that can be satisfactorily diagnosed by detailed history and physical examination with high patient satisfaction achieved after surgical management.