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.

The treatment of abdominoscrotal hydrocele: Is there a role for nonoperative management?

BACKGROUND/PURPOSE: Abdominoscrotal hydrocele (ASH) is an uncommon entity. Until now, the recommended treatment has been surgical. There is only one successful case of nonoperative management reported in literature. We report the largest series of children with ASH, and provide evidence in support of an initial nonoperative approach. METHODS: This study is a retrospective chart review of patients treated from 1994 to 2015 with ASH at a single institution. RESULTS: Thirty patients were identified with ASH, with 29 included in the analysis. Nine patients (30%) had operative management with an 80% complication rate. Twenty out of 29 patients (70%) were initially managed expectantly. Sixteen (80%) had resolution of their abdominal component, twelve (60%) of which went on to have full resolution of ASH. Four patients (20%) in this group required operative management of ASH. CONCLUSIONS: ASH should be included in the differential diagnosis of pediatric scrotal swelling. The "Springing Back Ball Sign" should be used as a screening tool. If it is positive, a dynamic ultrasound should be performed to confirm the diagnosis. We recommend observation as the first step in the management of uncomplicated ASH. It can result in avoidance of operation or at least lower the complication risk significantly if operation is required. LEVEL OF EVIDENCE: 4.

Spinal anesthesia for cesarean section in a patient with chronic inflammatory demyelinating polyradiculoneuropathy.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an inflammatory disorder of the peripheral nervous system with progressive or relapsing signs in more than one limb, ending in prolonged periods of disability. There are no guidelines for anesthesia in this uncommon paralyzing disease. This report features a 19-year-old woman with CIDP scheduled for an elective cesarean section who had prolonged recovery of motor function after the administration of spinal anesthesia. Although a partial neural block in both feet persisted for 1 day, we conclude that spinal anesthesia is acceptable for cesarean delivery in CIDP-patients when reasonable precautions have been taken.