An investigation on the compliance of perioperative practices using ERAS protocols and barriers to the implementation of the ERAS protocols in colorectal surgery.

BACKGROUND: Although ERAS protocols have many benefits, there are some deficiencies in their understanding and implementation by healthcare professionals. The present study was conducted to investigate the compliance of the current perioperative practices of healthcare professional with the ERAS protocols and to assess barriers to the implementation of ERAS protocols in colorectal surgery. METHODS: This cross-sectional descriptive study conducted in the surgical clinics and operating rooms of a training and research hospital between January 2020 and September 2020 included 110 physician and nurse members of surgical teams. Data were collected using the Questionnaire for Evaluating the Use of the ERAS Protocol and Identifying Barriers to Implementation in Colorectal Surgery. RESULTS: The compliance of the current perioperative practices by healthcare professionals with the ERAS protocols ranged between 15.5% (routinely leaving nasogastric tubes in situ following colorectal resection) and 61.8% (being aware of the concept of balanced analgesia). Variables such as the healthcare professional's profession, title, years in practice and colorectal surgery experience led to a difference between them in terms of their compliance of the practices with the ERAS protocols (p < 0.05). Based on the healthcare professionals' comments about barriers to the implementation of the ERAS protocol, themes such as education, teamwork, communication and lack of resources were created. CONCLUSION: Healthcare professionals' compliance level of the current perioperative practices with the ERAS protocols was mostly low. Barriers to the implementation of the ERAS protocols had a multi-factor structure that concerns the multidisciplinary team.

Racial disparities in survival of early onset colon cancer (Age<50): A matched NCDB analysis.

BACKGROUND: Early-onset colon cancer (EOCC) has increasing incidence and disproportionately affects African-Americans. This analysis aims to compare EOCC survival among Black and White patients after matching relevant socio-demographic factors and stage. METHODS: The 2004-2017 NCDB database was queried for Black and White patients, age<50, who underwent colectomy for adenocarcinoma. A one-to-one match on race was performed based on sociodemographic factors and disease stage (I-IV). Five-year survival differences were analyzed with Cox proportional hazards models. RESULTS: 5322 Black-White matched pairs were analyzed. Compared to White patients, Black patients averaged more days to surgery (19 â€‹± â€‹68 vs 16 days â€‹± â€‹32, p â€‹< â€‹0.001) and to chemotherapy (63 â€‹± â€‹8 vs. 57 â€‹± â€‹39, p â€‹< â€‹0.001). Black stage III patients were 20% less likely to receive chemotherapy (OR 0.8, 95% CI 0.7-0.9, p â€‹= â€‹0.0006), and had a 17% increased rate of death (HR 1.17, 95% CI 1.0-1.3, p â€‹= â€‹0.01) after adjusting for sex, comorbidity score, tumor location and chemotherapy. CONCLUSIONS: Black patients with stage 3 EOCC are less likely to receive chemotherapy and have worse survival. Further evaluation is warranted to identify potential factors driving these observed.

Management of left-sided malignant colorectal obstructions with curative intent: a network meta-analysis.

BACKGROUND: Several management options exist for colonic decompression in the setting of malignant large bowel obstruction, including oncologic resection, surgical diversion, and SEMS as a bridge-to-surgery. Consensus has yet to be reached on optimal treatment pathways. The aim of the present study was to perform a network meta-analysis comparing short-term postoperative morbidity and long-term oncologic outcomes between oncologic resection, surgical diversion, and self-expanding metal stents (SEMS) in left-sided malignant colorectal obstruction with curative intent. METHODS: Medline, Embase, and CENTRAL were systematically searched. Articles were included if they compared two or more of the following in patients presenting with curative left-sided malignant colorectal obstruction: (1) emergent oncologic resection; (2) surgical diversion; and/or (3) SEMS. The primary outcome was overall 90-day postoperative morbidity. Pairwise meta-analyses were performed with inverse variance random effects. Random-effect Bayesian network meta-analysis was performed. RESULTS: From 1277 citations, 53 studies with 9493 patients undergoing urgent oncologic resection, 1273 patients undergoing surgical diversion, and 2548 patients undergoing SEMS were included. Network meta-analysis demonstrated a significant improvement in 90-day postoperative morbidity in patients undergoing SEMS compared to urgent oncologic resection (OR0.34, 95%CrI0.01-0.98). Insufficient RCT data pertaining to overall survival (OS) precluded network meta-analysis. Pairwise meta-analysis demonstrated decreased five-year OS for patients undergoing urgent oncologic resection compared to surgical diversion (OR0.44, 95%CI0.28-0.71, p < 0.01). CONCLUSIONS: Bridge-to-surgery interventions may offer short- and long-term benefits compared to urgent oncologic resection for malignant colorectal obstruction and should be increasingly considered in this patient population. Further prospective study comparing surgical diversion and SEMS is needed.

S184: preoperative sarcopenia is associated with worse short-term outcomes following transanal total mesorectal excision (TaTME) for rectal cancer.

INTRODUCTION: Malnutrition and deconditioning impact postoperative morbidity and mortality. Computed tomography (CT) body composition variables are used as markers of nutritional status and sarcopenia. The objective of this study is to evaluate the impact of sarcopenia, using CT variables, on postoperative outcomes following transanal total mesorectal excision (TaTME) for rectal cancer. METHODS: This was an institutional retrospective cohort analysis of consecutive rectal cancer patients who underwent TaTME between April 2014 and May 2020. Psoas muscle index (PMI) was calculated from diagnostic CT scans. Based on previous studies, patients in the lowest PMI tertile by gender were considered sarcopenic. Fisher's exact and Mann-Whitney U test were used to compare categorical and continuous variables, respectively. Readmission rates and postoperative complications were compared between groups. Backward stepwise logistic regression was used to determine the association between sarcopenia and 30-day postoperative complications. RESULTS: 85 patients were analyzed, of which 63% were male, with a median age of 59 (IQR: 51-65), and median BMI of 28 (IQR: 24-32). Of the entire cohort, 34% (n = 29) were sarcopenic (median PMI 5.39 IQR: 4.49-6.71). No significant difference in baseline characteristics between sarcopenic and nonsarcopenic patients were observed. 55% of sarcopenic patients experienced a complication within 30 days compared to 24% of nonsarcopenic patients (p = 0.01). 41% of sarcopenic patients required hospital readmission within 30 days compared to 17% of their nonsarcopenic counterparts (p = 0.014). Sarcopenic patients also experienced significantly higher rates of post-operative small bowel obstruction (10% vs. 0%, p = 0.04). Multivariable analyses identified that sarcopenic patients have a fourfold increase in odds of experiencing a 30-day postoperative complication (OR: 4.44, 95%CI: 1.6-12.4, p < 0.05) after adjusting for gender. CONCLUSION: Preoperative sarcopenia is associated with increased 30-day postoperative complications following TaTME for rectal cancer. Postoperative complications can have serious oncologic implications by delaying adjuvant chemotherapy. Therefore, preoperative recognition of sarcopenia prior to undergoing TaTME for rectal cancer may provide an opportunity for early intervention with prehabilitation programs.

Total Transperineal Laparoscopic Proctectomy for the Treatment of Crohn's Proctitis.

INTRODUCTION: Completion proctectomy is traditionally performed using a combination of abdominal and perineal approaches. Access to and exposure of the pelvis through the abdominal cavity can be limited in patients with prior surgery or inflammatory conditions. We describe a novel technique for a total transperineal approach for proctectomy for Crohn's proctitis, avoiding technical challenges, risks, and recovery associated with abdominal surgery. TECHNIQUE: We utilized the skills and expertise acquired from our experience with transanal total mesorectal excision to perform a total transperineal laparoscopic proctectomy in a male patient with medically refractory proctitis. He previously underwent an anterior resection, drainage of a chronic presacral abscess, omental pedicle flap transposition to the pelvis, and end colostomy for severe Crohn's colitis. The total transperineal laparoscopic proctectomy approach avoids the need for abdominal access, including the risks associated with abdominal entry, adhesiolysis, pelvic access and visualization, and wound-related issues. Following an initial intersphincteric perineal dissection, the GelPOINT Path minimal access platform is utilized to perform a total transperineal proctectomy. RESULTS: The patient recovered uneventfully and was discharged to home 2 days after surgery. At 1-month postoperative follow-up, the patient is recovering well with complete healing of the perineal wound. CONCLUSION: We demonstrate the feasibility, safety, and technical steps of a minimally invasive completion proctectomy for fistulizing Crohn's proctitis by using a total transperineal approach. This approach allowed us to utilize direct, inline, high-definition visualization to access and safely operate in the distal aspects of a narrow, scarred, and fibrotic pelvis while avoiding the need for any abdominal access. Advanced experience with redo pelvic and minimally invasive transanal surgery is critical. See Video at http://links.lww.com/DCR/B664.

Regional Variation in Laparoscopy Use for Elective Colon Cancer Treatment in Canada: The Importance of Fellowship Training Sites.

BACKGROUND: Over the last decade, use of laparoscopy for the treatment of colon cancer has been variable despite evidence of benefit, possibly reflecting surgeon expertise rather than other factors. OBJECTIVE: The purpose of this study was to examine the spatial variation in the use of laparoscopy for colon cancer surgery and to determine what factors may influence use. DESIGN: This was a population-based retrospective analysis from April 2008 to March 2015. SETTINGS: All Canadian provinces (excluding Quebec) were included. PATIENTS: The study included all patients ≥18 years of age undergoing elective colectomy for colon cancer. MAIN OUTCOME MEASURES: The primary outcome was laparoscopy use rates. Predictors of use included patient and disease characteristics, year of surgery, rurality, hospital and surgeon volumes, and distance from a colorectal fellowship training center. RESULTS: A total of 34,725 patients were identified, and 42% underwent laparoscopic surgery. Significant spatial variations in laparoscopy use were identified, with 95% of high-use clusters located ≤100 km and 98% of low-use clusters located >100 km from a colorectal fellowship center. There were no high-use clusters located around large academic centers without colorectal fellowships. At the individual level, patients living within 25 km and 26 to 100 km of a fellowship center were 2.6 and 1.6 times more likely to undergo laparoscopic surgery compared with those >100 km away (95% CI, 2.47-2.79, p < 0.00; 95% CI, 1.53-1.71, p < 0.001). Surgeon and hospital volumes were associated with increased rates of laparoscopy use (p < 0.001). LIMITATIONS: Data were obtained from an administrative database, and despite 85% to 95% published validity, they remain subject to misclassification, response, and measurement bias. CONCLUSIONS: Significant spatial variations in the use of laparoscopy for colon cancer surgery exist. After adjusting for patient and system factors, proximity to a colorectal fellowship training center remained a strong predictor of laparoscopy use. There remain regional variations in colon cancer treatment, with discrepancies in the surgical care offered to Canadian patients based solely on location. See Video Abstract at http://links.lww.com/DCR/B595. VARIACIN REGIONAL EN EL USO DE LAPAROSCOPIA PARA EL TRATAMIENTO ELECTIVO DEL CNCER DE COLON EN CANAD LA IMPORTANCIA DE LOS SITIOS DE CAPACITACIN PARA RESIDENTES: ANTECEDENTES:Durante la última década, la utilización de la laparoscopia para el tratamiento del cáncer de colon ha sido variable a pesar de la evidencia de beneficio; posiblemente reflejando la experiencia del cirujano, más que otros factores.OBJETIVO:Examinar la variación espacial en el uso de la laparoscopia para la cirugía del cáncer de colon y determinar qué factores pueden influir en la utilización.DISEÑO:Análisis retrospectivo poblacional de abril de 2008 a marzo de 2015.ENTORNO CLÍNICO:Todas las provincias canadienses (excepto Quebec).PACIENTES:Todos los pacientes> 18 años sometidos a colectomía electiva por cáncer de colon.PRINCIPALES MEDIDAS DE RESULTADO:El principal resultado fueron las tasas de utilización de laparoscopia. Los predictores de uso incluyeron las características del paciente y la enfermedad, el año de la cirugía, la ruralidad, los volúmenes de hospitales y cirujanos, y la distancia a un centro de formación de residentes colorectales.RESULTADOS:Se identificaron 34.725 pacientes, 42% fueron sometidos a cirugía laparoscópica. Se identificaron variaciones espaciales significativas en el uso de laparoscopia, con el 95% de los conglomerados de alto uso ubicados a <100 km y el 98% de los conglomerados de bajo uso ubicados a> 100 km, desde un centro de residencia colorectal. No había grupos de alto uso ubicados alrededor de grandes centros académicos sin residentes colorrectales. A nivel individual, los pacientes que vivían dentro de los 25 km y 26-100 km de un centro de residentes tenían 2,6 y 1,6 veces más probabilidades de someterse a una cirugía laparoscópica, respectivamente, en comparación con aquellos a> 100 km de distancia (95% CI 2,47-2,79, p <0,00; IC del 95% 1,53-1,71, p <0,001). Los volúmenes de cirujanos y hospitales se asociaron con mayores tasas de utilización de laparoscopia (p <0,001).LIMITACIONES:Los datos se obtuvieron de una base de datos administrativa y, a pesar de una validez publicada del 85-95%, siguen sujetos a errores de clasificación, respuesta y sesgo de medición.CONCLUSIONES:Existen variaciones espaciales significativas en el uso de la laparoscopia para la cirugía del cáncer de colon. Después de ajustar por factores del paciente y del sistema, la proximidad a un centro de formación de residentes colorectales siguió siendo un fuerte predictor del uso de laparoscopia. Sigue habiendo variaciones regionales en el tratamiento del cáncer de colon, con discrepancias en la atención quirúrgica ofrecida a los pacientes canadienses basadas únicamente en la ubicación. Consulte Video Resumen en http://links.lww.com/DCR/B595.

Influence of undergraduate medical education exposure to cadaveric dissection on choice of surgical specialty: a national survey of Canadian surgical residents.

Background: The number of Canadian Residency Matching Service (CaRMS) applicants ranking surgical specialties as their first choice has declined over the past 20 years; concurrently, there has been a reduction in the number of hours spent teaching undergraduate medical education (UGME) anatomy, particularly with cadaveric dissection. The aim of this study was to determine the factors that most influence selection of a surgical specialty, with specific focus on the impact of UGME anatomy training. Methods: A 36-item cross-sectional survey was designed by experts in medical education and distributed to all current surgical residents in Canada in October 2018. Responses were recorded on a 5-point Likert scale or by means of list ranking. We analyzed univariable outcomes with a t test for continuous outcomes and the χ2 test for dichotomous outcomes. Results: Of 1493 surgical residents, 228 responded to the survey (response rate 15.3%). Respondents reported experiences on core rotations and elective rotations, and access to a mentor as the most important factors in deciding to pursue a surgical residency. Anatomy training with or without cadaveric dissection was moderately influential in respondents' first-choice CaRMS discipline (mean Likert scale score 2.97 [standard deviation (SD) 1.34] and 2.87 [SD 1.26], respectively). General surgery residents' CaRMS applications were more likely to have been influenced by UGME anatomy training than the applications by residents in other surgical specialties (p < 0.001). The impact of UGME anatomy training did not vary between postgraduate years or between male and female residents. Conclusion: Canadian surgical residents' decision to apply to a surgical specialty did not seem to be strongly influenced by their UGME anatomy training, with or without cadaveric dissection, but, rather, by factors such as clinical experience and surgical mentorship. Further evaluation of groups that were more positively affected by their UGME anatomy training is warranted.

Contexte: Le nombre de candidats inscrits au Service de jumelage canadien des résidents (SJCR) qui classent les spécialités chirurgicales parmi leurs premiers choix a diminué ces 20 dernières années. Simultanément, dans les programmes d'études médicales prédoctorales, on a noté une baisse du nombre d'heures consacrées à l'enseignement de l'anatomie, particulièrement à la dissection de cadavres. Le but de cette étude était d'identifier les principaux facteurs qui influent sur le choix d'une spécialité chirurgicale, en portant une attention particulière à l'impact de la formation prédoctorale en anatomie. Méthodes: Des experts en formation médicale ont préparé un sondage de 36 questions qui a été distribué à tous les résidents en chirurgie au Canada en date d'octobre 2018. Les réponses ont été reportées sur une échelle de Likert en 5 points ou sous forme de liste de classement. Nous avons analysé les résultats univariés au moyen d'un test t pour les résultats continus et d'un test du χ2 pour les variables dichotomiques. Résultats: Sur 1493 résidents en chirurgie, 228 ont répondu au sondage (taux de réponse, 15,3 %). Parmi les plus importants facteurs pour décider de poursuivre leur résidence, les répondants ont mentionné leurs expériences de stages obligatoires et électifs et l'accès à un mentor. La formation en anatomie, avec ou sans dissection de cadavres, a eu une influence modérée sur le premier choix d'une discipline du SJCR (score moyen à l'échelle de Likert 2,97 [écart-type (É.-T.) 1,34] et 2,87 [É.-T. 1,26], respectivement). Les demandes d'admission des résidents en chirurgie générale étaient plus susceptibles de dépendre de la formation prédoctorale en anatomie que les demandes d'admission dans d'autres spécialités chirurgicales (p < 0.001). L'impact de la formation prédoctorale en anatomie n'a pas varié en fonction de l'année de résidence ni selon le sexe des résidents. Conclusion: La décision des résidents de chirurgie canadiens de s'inscrire dans une spécialité chirurgicale n'a pas semblé fortement influencée par la formation prédoctorale en anatomie, avec ou sans dissection de cadavres, mais plutôt par des facteurs tels que l'expérience clinique et le mentorat en chirurgie. Il faudrait étudier plus en profondeur les groupes pour qui la formation prédoctorale en anatomie a été positive.

Presentation and survival among patients with colorectal cancer before the age of screening: a systematic review and meta-analysis.

Background: The incidence of colorectal cancer in North America is rising among patients younger than 50 years. Available data are conflicting regarding presentation and outcomes in this population. This review aimed to synthesize literature regarding young patients with colorectal cancer with respect to patient demographics, disease extent and survival, compared with patients older than 50 years. Methods: We searched Medline, Embase, the Cochrane Central Register of Controlled Trials and PubMed for articles published between 1990 and the time of search. Articles comparing North American patients with colorectal cancer younger and older than 50 years were eligible for inclusion. We used a random-effects model to pool odds ratios. Results: Eight retrospective studies were eligible for inclusion (n = 790 959). Mean age was 42.6 years (standard deviation [SD] 5.07) in the younger group, and 69.1 years (SD 9.25) in the older group. Young patients were more likely to present with regional (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.16-1.40) and distant disease (OR 1.47, 95%CI 1.30-1.67). Considering patients at all stages of disease, differences in 5-year overall survival (OR 1.54, 95%CI 0.96-2.47) and cancer-specific survival (OR 1.01, 95%CI 0.91-1.13) were not statistically significant between groups. However, when controlling for disease extent, 5-year cancer-specific survival was significantly higher among young patients with local (OR 1.69, 95%CI 1.43-1.99), regional (OR 1.37, 95%CI 1.16-1.63) and distant disease (OR 1.79, 95%CI 1.45-2.21). Conclusion: North American patients presenting with colorectal cancer before the age of 50 years are more likely to have advanced disease. Although overall and cancer-specific survival is not significantly different between these groups, younger patients have improved survival when controlling for cancer stage.

Contexte: L'incidence du cancer colorectal en Amérique du Nord est en hausse chez les patients de moins de 50 ans. Les données disponibles quant à la présentation et aux issues de la maladie dans cette population sont contradictoires. La présente revue systématique vise à synthétiser les données de la littérature sur les jeunes patients atteints d'un cancer colorectal, entre autres les caractéristiques démographiques des patients, le stade de la maladie et le taux de survie, et à les comparer aux données des patients de plus de 50 ans. Méthodes: Nous avons interrogé les bases de données Medline, Embase, PubMed et le Cochrane Central Register of Controlled Trials pour repérer les articles publiés entre 1990 et le moment de la recherche. Les études comparants les patients nord-américains atteints d'un cancer colorectal de moins de 50 ans et ceux de plus de 50 ans ont été incluses. Nous avons utilisé un modèle à effets aléatoires pour regrouper les rapports de cotes. Résultats: Huit études rétrospectives ont été retenues (n = 790 959). L'âge moyen était de 42,6 ans (écart type [É. T.] 5,07) pour le groupe des moins de 50 ans, et de 69,1 ans (É.-T. 9,25) pour l'autre groupe. Les jeunes patients étaient plus susceptibles de présenter un cancer régional (rapport de cotes [RC] 1,27; intervalle de confiance [IC] à 95 % 1,16­1,40) ou un cancer à distance (RC 1,47; IC à 95 % 1,30­1,67). Si on ne tenait pas compte du stade de la maladie, la différence entre le taux de survie globale à 5 ans (RC 1,54; IC à 95 % 0,96­2,47) et le taux de survie au cancer à 5 ans (RC 1,01; IC à 95 % 0,91­1,13) n'était pas statistiquement significative. Toutefois, si on tenait compte de l'étendue de la maladie, le taux de survie lié au cancer à 5 ans était significativement plus élevé chez les jeunes patients ayant un cancer localisé (RC 1,69; IC à 95 % 1,43­1,99), régional (RC 1,37; IC à 95 % 1,16­1,63) ou à distance (RC 1,79; IC à 95 % 1,45­2,21). Conclusion: Les patients nord-américains de moins de 50 ans présentant un cancer colorectal sont plus susceptibles d'être à un stade avancé de la maladie. Bien que le taux de survie globale et le taux de survie au cancer ne diffèrent pas de manière significative entre les 2 groupes, les jeunes patients présentaient un meilleur taux de survie lorsqu'on tenait compte du stade de la maladie.

Operative management of colonic diverticular disease in the setting of immunosuppression: A systematic review and meta-analysis.

BACKGROUND: Immunosuppressed patients with diverticular disease are at higher risk of postoperative complications, however reported rates have varied. The aim of this study is to compare postoperative outcomes in immunosuppressed and immunocompetent patients undergoing surgery for diverticular disease. METHODS: Medline, EMBASE, and CENTRAL were searched. Articles were included if they compared immunosuppressed and immunocompetent patients undergoing surgery for diverticular disease. RESULTS: From 204 citations, 11 studies with 2,977 immunosuppressed patients and 780,630 immunocompetent patients were included. Mortality was greater in immunosuppressed patients compared to immunocompetent patients for emergent surgery (RR 1.91, 95%CI 1.24-2.95, p < 0.01), but not elective surgery (RR 1.70, 95%CI 0.14-20.47, p = 0.68). Morbidity was greater in immunosuppressed patients compared to immunocompetent patients for elective surgery (RR 2.18, 95%CI 1.02-4.65, p = 0.04), but not emergent surgery (RR 1.40, 95%CI 0.68-2.90, p = 0.37). CONCLUSIONS: Increased consideration for elective operation may preclude the need for emergent surgery and the associated increase in postoperative mortality.

The predictors of Enhanced Recovery After Surgery utilization and practice variations in elective colorectal surgery: a provincial survey.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization. METHODS: A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization. RESULTS: Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively). CONCLUSION: Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.

CONTEXTE: Les protocoles de récupération optimisée après une chirurgie (ou ERAS, pour enhanced recovery after surgery) utilisent des pratiques périopératoires fondées sur des données probantes pour réduire la morbidité, abréger la durée des séjours hospitaliers et améliorer la satisfaction des patients. Les protocoles ERAS sont considérés comme une norme thérapeutique; toutefois, leur utilisation reste faible et on note une importante variation dans leur application. Le but de cette étude était de caractériser dans les faits les variations des pratiques en chirurgie colorectale et d'identifier les prédicteurs de l'utilisation des protocoles ERAS. MÉTHODES: Un sondage a été effectué auprès des chirurgiens généraux de la base de données du Collège des médecins et chirurgiens de l'Ontario. On a recueilli des données sur les caractéristiques démographiques de base, l'utilisation des protocoles ERAS et les prédicteurs de leur déploiement. Neuf pratiques ERAS ont été analysées. L'analyse multivariée a permis de déterminer les effets des covariables démographiques, hospitalières et celles des chirurgiens sur le recours aux protocoles ERAS. RÉSULTATS: Nous avons invité 797 chirurgiens généraux à participer au sondage, et 235 d'entre eux représentant 84 hôpitaux ontariens y ont répondu (taux de réponse 30 %). Les chirurgiens des établissements universitaires et des grands hôpitaux communautaires ont représenté respectivement 30 % et 47 % des répondants. En tout, 20 % des répondants ont déclaré appliquer les 9 pratiques ERAS de manière constante. L'alimentation précoce au Jour 0 postopératoire, la restriction des liquides intraveineux et les directives concernant les cathéters et les sondes étaient significativement mieux observées chez les répondants qui adhéraient aux protocoles ERAS que chez ceux qui n'y adhéraient pas (74 % c. 54 %, p = 0,004; 92 % c. 80 %, p = 0,01; et 91 % c. 41 %, p < 0,001, respectivement). Les répondants des milieux universitaires ont indiqué appliquer près de 1 comportement ERAS de plus que ceux des petits hôpitaux communautaires (rapport des cotes [RC] 0,86, intervalle de confiance [IC] de 95 % de 0,42 à 1,31, p < 0,001). L'analyse multivariée a démontré que la spécialisation en chirurgie colorectale ou l'exposition aux protocoles ERAS en cours de formation n'ont pas significativement influé sur l'application des pratiques ERAS (RC 0,32, IC de 95 % de ­0,31 à 0,94, p = 0,16; RC 0,28, IC de 95 % de ­0,26 à 0,82, p = 0,16, respectivement). CONCLUSION: On continue d'observer une importante variation des pratiques en chirurgie colorectale. Les principes ERAS individuels sont généralement suivis, mais ils ne sont pas formellement intégrés aux protocoles hospitaliers.

The role of fecal calprotectin in the diagnosis of acute pouchitis following IPAA for ulcerative colitis: a systematic clinical review.

PURPOSE: Total proctocolectomy (TPC) with ileal pouch anal anastomosis (IPAA) is commonly performed for patients with refractory ulcerative colitis (UC). Pouchitis occurs in 20-50% of these patients. Fecal calprotectin is a biomarker that correlates well with the pouchitis disease activity index. However, its role in the diagnosis and management of acute pouchitis has not been thoroughly defined. The aim of this study is to review previously established cut-off values and contextualize the clinical utility of fecal calprotectin. METHODS: Search of Medline, EMBASE, CENTRAL, and PubMed was performed. Articles were eligible if they measured fecal calprotectin in the setting of pouchitis in patients who underwent TPC with IPAA for UC. Risk of bias of the included studies was evaluated with the QUADAS-2. RESULTS: From 117 relevant citations, seven studies with 256 patients (44.8% female, 39.88 years) met inclusion criteria. The pooled prevalence of pouchitis was 42%. The derived fecal calprotectin cut-off values ranged from 56 to 494 µg/g. The corresponding sensitivities and specificities ranged from 57 to 100% and 38 to 92%, respectively. The area under the curve was reported in three studies and ranged from 0.832 to 0.840. CONCLUSION: Fecal calprotectin may be a reliable diagnostic tool for acute pouchitis in patients following TPC with IPAA for UC. The high sensitivity of fecal calprotectin for detection of pouchitis makes it a valuable test for ruling out pouchitis. When used in conjunction with other biomarkers, the high specificity offers value in ruling in pouchitis. However, given the complexity of this disease process, relying solely on biomarkers for diagnosis is currently unreasonable.

Examining the transferability of colon and rectal operative experience on outcomes following laparoscopic rectal surgery.

BACKGROUND: Laparoscopic rectal surgery is technically challenging and often low volume. Alternatively, colon resections utilize similar advanced laparoscopic skills and are more common but it is unknown whether this experience affects laparoscopic rectal surgery outcomes. The purpose of this paper is to determine the volume-outcome relationship between several colorectal procedures and laparoscopic rectal surgery outcomes. METHODS: This was a population-based retrospective cohort of all colorectal surgeries with primary anastomoses performed across Canada (excluding Quebec) between April 2008 and March 2015. Patient characteristics, comorbidities, procedures, and discharge details were collected from the Canadian Institute for Health Information. Volumes for common colorectal procedures were calculated for individual surgeons. All-cause morbidity, defined as complications arising during the index admission and contributing to an increased length of stay by more than 24 h, was the primary outcome examined. RESULTS: A total of 5323 laparoscopic rectal surgery cases and 108,034 colorectal cases, between 180 hospitals and 620 surgeons, were identified. Data analysis demonstrated that high-volume laparoscopic rectal surgeons (OR 0.77, CI 0.61-0.96, p = 0.020) and high-volume open rectal surgeons (OR 0.76, CI 0.61-0.93, p = 0.009) significantly reduced all-cause morbidity. Conversely, surgeon volumes for laparoscopic and open colon cases had no effect on laparoscopic rectal outcomes. CONCLUSION: High-volume surgeon status in laparoscopic and open rectal surgery are important predictors of all-cause morbidity after laparoscopic rectal surgery, while laparoscopic colon surgery volumes did not impact outcomes. This may reflect more dissimilarity between colon and rectal cases and less transferability of advanced laparoscopic skills than previously thought.

Diverting loop ileostomy with colonic lavage as an alternative to colectomy for fulminant Clostridioides difficile: a systematic review and meta-analysis.

PURPOSE: Surgical consultation is recommended for all patients with fulminant Clostridioides difficile infection (CDI). If surgery is required, total abdominal colectomy (TAC) is most commonly performed. However, diverting loop ileostomy and colonic lavage have been recently developed as a potential colon-sparing approach to fulminant CDI. The aim of this review is to compare TAC and diverting loop ileostomy with colonic lavage for fulminant CDI. METHODS: Search of MEDLINE, EMBASE, CENTRAL, and PubMed was performed. Articles were eligible for inclusion if they compared TAC and diverting loop ileostomy with colonic lavage. The primary outcome was postoperative mortality, and the secondary outcome was postoperative complications. Quality of included studies was assessed using Newcastle-Ottawa Scale. RESULTS: From 64 relevant citations, 5 studies (4 retrospective cohorts, 1 case series) with 3683 patients were included. Compared to TAC, diverting loop ileostomy with colonic lavage did not significantly reduce overall mortality (RR 1.10, 95% CI 0.60 to 1.99, P = 0.77), rate of reoperation (RR 1.02, 95% CI, 0.63 to 1.63, P = 0.94), or overall postoperative complications (RR 0.51, 95% CI, 0.22 to 1.17, P = 0.11). Rates of colonic preservation with the use of diverting loop ileostomy with colonic lavage ranged from 76% to 100%. CONCLUSION: There does not appear to be a survival advantage with the use of diverting loop ileostomy with colonic lavage compared to TAC for fulminant CDI. However, diverting loop ileostomy with colonic lavage results in increased rates of colonic preservation, restoration of intestinal continuity, and laparoscopic surgery. This review is limited by the small number of included studies.

Regional Variation in the Utilization of Laparoscopy for the Treatment of Rectal Cancer: The Importance of Fellowship Training Sites.

BACKGROUND: Compared to open rectal surgery, laparoscopy is associated with lower perioperative morbidity but unclear oncologic outcomes. Unique technical challenges exist with laparoscopic rectal surgery and access based on geographical location is unknown. The purpose of this study was to determine whether proximity to colorectal fellowship training sites influences laparoscopy utilization for rectal cancer surgery. METHODS: Population based retrospective spatial analysis assessing regional rates of laparoscopy use in patients (≥ 18 years of age) undergoing rectal cancer surgery in Canada (excluding Quebec) from April 2008 to March 2014. RESULTS: Overall, 11,261 patients underwent rectal cancer surgery. Four Canadian colorectal fellowship training centers were identified. Rectal surgeries were performed laparoscopically 27% of the time, and this significantly increased from 18.1 to 40.3% between 2008 and 2014. Multivariate analysis adjusting for province, disease, hospital, patient, and surgeon factors demonstrated that patients living within 25 km of a colorectal fellowship training site had 2.5 times higher odds of laparoscopy use and those living within 26-100 km had 1.8 times higher odds of laparoscopy [95% confidence interval (CI) 2.14-2.71, p < 0.001, 95% CI 1.64-2.07, p < 0.001 respectively]. High-volume surgeons and hospitals were associated with increased laparoscopy use (1.25, 95% CI 1.11-1.4 and 1.36, 95% CI 1.21-1.53, p < 0.001 respectively). CONCLUSIONS: Significant geographical variation to laparoscopic rectal cancer surgery access in a publicly funded healthcare system currently exists. The inverse relationship between colorectal fellowship training site distance and undergoing a laparoscopic rectal surgery highlights the current disparities in Canadian health care and the need for surgical mentorship to increase uptake of advanced surgical techniques in rural neighbourhoods.

Optimal timing of urinary catheter removal following pelvic colorectal surgery: a systematic review and meta-analysis.

PURPOSE: Acute urinary retention (AUR) is a common postoperative complication in colorectal surgery. In pelvic colorectal operations, the optimal duration for postoperative urinary catheter use is controversial. This systematic review and meta-analysis aims to compare early (POD 1), intermediate (POD 3), and late (POD 5) urinary catheter removal. METHODS: Medline, EMBASE, CENTRAL, and PubMed databases were searched. Articles were eligible for inclusion if they compared patients with urinary catheter removal on POD 1 or earlier to patients with urinary catheter removal on POD 2 or later in major pelvic colorectal surgeries. The primary outcome was rate of postoperative AUR. The secondary outcome was rates of postoperative urinary tract infection (UTI). RESULTS: From 691 relevant citations, five studies with 928 patients were included. Comparison of urinary catheter removal on POD 1 versus POD 3 demonstrated no significant difference in rate of urinary retention (RR 1.36, 95%CI 0.83-2.21, P = 0.22); however, compared to POD 5, rates of AUR were significantly higher (RR 2.58, 95%CI 1.51-4.40, P = 0.0005). Rates of UTI were not significantly different between POD 1 and POD 3 urinary catheter removal (RR 0.40, 95%CI 0.05-3.71, P = 0.45), but removal on POD 5 significantly increased risk of UTI compared to POD 1 (RR 0.50, 95%CI 0.31-0.81, P = 0.005). CONCLUSION: Risk of AUR can be minimized with late postoperative urinary catheter removal compared to early removal, but at the cost of increased risk of UTI. Patient-specific factors should be taken into consideration when deciding upon optimal duration of postoperative urinary catheterization.

Prone Compared With Lithotomy for Abdominoperineal Resection: A Systematic Review and Meta-analysis.

BACKGROUND: Abdominoperineal resection (APR) is the primary surgical approach to low rectal cancers. Both prone and lithotomy patient positioning during the perineal dissection are currently acceptable approaches. There is no consensus on whether patient positioning has an impact on operative and oncologic outcomes. The aim of this review was to compare the perioperative and long-term oncologic outcomes between prone and lithotomy patient positioning. MATERIALS AND METHODS: Search of Medline, Embase, Web of Science, CENTRAL, PubMed, and ClinicalTrials.gov databases was performed. Articles were eligible for inclusion if they compared prone and lithotomy positioning for the perineal portion of APR for rectal cancer in one of the primary outcomes. Quality of included studies was assessed using Newcastle-Ottawa Scale and Cochrane Risk of Bias Tool. RESULTS: Nine studies with 888 patients in the prone group and 897 in the lithotomy group were included. Compared with lithotomy position, prone position had a significantly lower perforation rate (risk ratio: 0.50, 95% confidence interval [CI]: 0.32 to 0.79, P = 0.003) and rates of positive circumferential resection margin involvement (risk ratio: 0.66, 95% CI: 0.44 to 1.00, P = 0.05). Prone position also had a significantly shorter operative time than lithotomy position (mean difference: -45.20 min, 95% CI: -63.03 to -27.36, P < 0.00001). Positioning did not affect 5-y overall survival or local and distal recurrence. CONCLUSIONS: Prone positioning may lead to lower rates of perforation and circumferential resection margin involvement in APR. In addition, it may lead to shorter operative time. Larger randomized studies are required to confirm the results of this review and examine the difference in long-term outcomes.

Drivers of Inpatient Costs After Colorectal Surgery Within a Publicly Funded Healthcare System.

BACKGROUND: The morbidity and mortality associated with colorectal resections are responsible for significant healthcare use. Identification of efficiencies is vital for decreasing healthcare cost in a resource-limited system. OBJECTIVE: The purpose of this study was to characterize the short-term cost associated with all colon and rectal resections. DESIGN: This was a population-based, retrospective administrative analysis. SETTINGS: This analysis was composed of all colon and rectal resections with anastomosis in Canada (excluding Quebec) between 2008 and 2015. PATIENTS: A total of 108,304 patients ≥18 years of age who underwent colon and/or rectal resections with anastomosis were included. MAIN OUTCOME MEASURES: Total short-term inpatient cost for the index admission and the incremental cost of each comorbidity and complication (in 2014 Canadian dollars) were measured. Cost predictors were modeled using hierarchical linear regression and Monte Carlo Markov Chain estimation. RESULTS: Multivariable regression demonstrated that the adjusted average cost of a 50-year-old man undergoing open colon resection for benign disease with no comorbidities or complications was $9270 ((95% CI, $7146-$11,624; p = <0.001). With adjustment for complications, laparoscopic colon resections carried a cost savings of $1390 (95% CI, $1682-$1099; p = <0.001) compared with open resections. Surgical complications were the main driver for increased cost, because anastomotic leaks added $9129 (95% CI, $8583-$9670; p = <0.001). Medical complications such as renal failure requiring dialysis ($16,939 (95% CI, $15,548-$18,314); p = <0.001) carried significant cost. Complications requiring reoperation cost $16,313 (95% CI, $15,739-$16,886; p = <0.001). The costliest complication cumulatively was reoperation, which exceeded $95 million dollars over the course of the study. LIMITATIONS: Inherent biases associated with administrative databases limited this study. CONCLUSIONS: Medical and surgical complications (especially those requiring reoperation) are major drivers of increased resource use. Laparoscopic colorectal resection with or without adjustment for complications carries a clear cost advantage. There is opportunity for considerable cost savings by reducing specific complications or by preoperatively optimizing select patients susceptible to costly complication. See Video Abstract at http://links.lww.com/DCR/A839.

A Provincial Assessment of the Barriers and Utilization of Enhanced Recovery After Colorectal Surgery.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols after colorectal surgery use several perioperative, intraoperative and postoperative interventions that decrease morbidity, length of stay, and improve patient satisfaction. ERAS is increasingly being considered standard of care; however, uptake of formalized protocols remains low. The objective is to characterize the provincial rates of ERAS utilization after colorectal surgery and identify barriers and limitations to ERAS implementation. METHODS: A total of 797 general surgeons were identified through the College of Physicians and Surgeons of Ontario. A survey identifying demographics, rates of ERAS utilization, and barriers to implementation was distributed. Logistic regression determined the effects of demographic and hospital covariates on ERAS utilization. RESULTS: A total of 235 general surgeons representing 84 Ontario hospitals participated (response rate 29.5%). Surgeons working in academic or large community hospitals represented the majority of the cohort (30.5% and 47.2%, respectively). Multivariable analysis showed no significant effect of surgeon demographics, years in practice, or training details on ERAS protocol utilization; however, practicing in small community hospitals (compared with large and academic hospitals) was significantly associated with not using ERAS protocols (odds ratio, 0.02; 95% confidence interval, 0-0.3; P = 0.005). Over 50% of respondents used ERAS principles but did not have a formal protocol. Barriers to implementing ERAS protocols included patient variability, lack of institutional and nursing support, and poor communication with the care team. CONCLUSIONS: Small community hospitals are less likely to use formal ERAS protocols; however, most Ontario surgeons are using ERAS principles after colorectal surgery. Barriers to ERAS implementation are broad and the present study has provided a pragmatic solution to change.

Does Imaging Before Percutaneous Drain Removal Affect Rates of Intra-abdominal Abscess Recurrence?

BACKGROUND: Intra-abdominal abscesses account for a large proportion of surgical complications and carry high mortality if not promptly controlled. Image-guided percutaneous drainage is standard of care. The objective of the study was to identify factors that predict abscess recurrence after percutaneous drain (PD) removal and determine if imaging before drain removal effects recurrence. METHODS: A consecutive multicenter retrospective cohort analysis of all patients who underwent PD insertion for abscesses between January 1, 2015, and December 31, 2015, was performed. Patient characteristics, PD details, and abscess recurrence were assessed. RESULTS: One hundred eighty-eight patients underwent PD insertion for spontaneous or postoperative abscesses, and overall abscess recurrence was 21%. Drains remained in situ for a median of 21.5 d (interquartile range: 9-42 d) with antibiotics used in 91% of cases. Forty-seven patients (25%) had a sinogram before PD removal, while 22% had computed tomography (CT) scans and 11% had ultrasounds. Hierarchical multivariable regression analysis showed that imaging before PD removal was associated with a 66% reduction in the odds of abscess recurrence (OR 0.34; 95% confidence interval [CI] 0.13-0.70; P = 0.006). Sinogram use was associated with an 86% reduction in the odds of recurrence (OR 0.14; 95% CI 0.02-0.39; P = 0.002) and ultrasound use was associated with a 78% reduction in the odds of recurrence (OR 0.22; 95% CI 0.02-0.76; P = 0.044) while CT use was not associated with a significant reduction in recurrence. CONCLUSIONS: Imaging before PD removal is associated with a reduction in the rates of abscess recurrence and requirement for additional drainage procedures or surgery. In addition, CT is not superior to ultrasound or sinograms as an imaging modality.

The effect of simethicone on postoperative ileus in patients undergoing colorectal surgery (SPOT), a randomized controlled trial.

BACKGROUND: Postoperative ileus is a poorly understood multifactorial outcome following colorectal surgery that presents significant clinical challenges and contributes to increased morbidity, length of stay, and healthcare cost. To date, there are few pharmacological interventions that shorten the duration of postoperative ileus. OBJECTIVE: This study is the first to evaluate the efficacy of simethicone in treating postoperative ileus symptoms in patients undergoing colorectal surgery. DESIGN: A multicenter, double-blinded, placebo controlled randomized controlled trial. SETTINGS: This trial was conducted at two academic tertiary care centres in Ontario, Canada. PARTICIPANTS: 118 patients undergoing colorectal surgery. INTERVENTIONS: Patients were randomized to receive either a five-day course of oral simethicone (n = 58) or a placebo (n = 60). MAIN OUTCOME MEASURES: The primary outcome was time to first passage of flatus. Secondary outcomes included time to first bowel movement, postoperative length of stay, and postoperative pain. Statistical analyses were performed on an intention-to-treat basis. Statistical significance set at p = 0.05. RESULTS: The median time to first passage of flatus in simethicone arm was 25.2 h and 26.7 h in controls (P = 0.98). There were no significant differences in the median time to first bowel movement (simethicone = 41.1 h vs. control = 42.9 h, P = 0.91) or median length of hospital stay (simethicone = 4.5 days vs. control = 4.0 days, P = 0.63). CONCLUSIONS: This study failed to show a difference in return of gastrointestinal motility in patients receiving simethicone following colorectal surgery. Postoperative ileus remains a significant clinical and economic burden to the healthcare system and further research is needed to identify a reliable and effective method of treatment.