Implementation of Synoptic Reporting for Endoscopic Localization of Complex Colorectal Neoplasms.

Introduction  Lack of documented tattooing of colorectal neoplasms at index colonoscopy results in high repeat preoperative colonoscopy rates. We developed national consensus recommendations for endoscopic localization and piloted an electronic synoptic reporting template. We report on the implementation and perceptions of using synoptic reporting to enhance colorectal lesion marking in a central Canadian healthcare system.  Methods We implemented the template within our endoscopy reporting system and ran an infographic education campaign. We then conducted a follow-up email-based interview with all regional endoscopists. Thematic analysis and a mixed-methods triangulation approach were employed to synthesize qualitative and quantitative data.  Results The interview was completed by 28/52 endoscopists (54%). Most (60.7%; n = 17) completed >100 colonoscopies and 71.4% (n = 20) identified six to 20 neoplasms requiring tattooing since introduction. A total of 50% (n = 14) used the template. Those not using it were unaware of it (42.9%; n = 12), or preferred using narrative text (17.9%; n = 5). Users reported modest mean functionality scores (intuitiveness: 3.56/5; efficiency: 3.7/5) and high impact scores (credible: 4.22/5; informative: 4.21/5). However, the perception of the synoptic template's ability to reduce the repeat preoperative colonoscopy rate was more circumspect (3.76/5). Conclusions Endoscopists believed the synoptic template was a functional, impactful tool that would improve communication and help to decrease the repeat preoperative colonoscopy rate. However, synoptic template uptake was limited by provider awareness, therefore more educational efforts are needed to increase uptake.

A comparison of perineal stapled prolapse resection and the Altemeier procedure at 2 Canadian academic hospitals.

BACKGROUND: The preferred perineal repair method for full-thickness rectal prolapse is the Altemeier procedure, a perineal proctosigmoidectomy with handsewn anastomosis. A recently described variant of this procedure combines the resection and anastomosis into 1 step by means of linear and transverse stapling. There are few published data comparing the characteristics and outcomes of these 2 approaches. METHODS: This retrospective review, performed at 2 Canadian academic hospitals, compares surgical and cost outcomes between the perineal stapled prolapse resection (PSPR) and the Altemeier procedure. All patients who underwent these procedures between 2015 and 2019 were included. RESULTS: There were 25 patients in the PSPR group and 19 in the Altemeier group. Patients in the PSPR group were significantly older than those in the Altemeier group (81 [95% confidence interval (CI) 70-92] yr v. 74 [95% CI 63-85] yr; p = 0.047), had a lower body mass index (21.4 [95% CI 17.7-25.1] v. 24.4 [95% CI 18.5-30.3]; p = 0.042) and had equivalent American Society of Anesthesiologists scores (2.84 [95% CI 2.09-3.59] v. 2.68 [95% CI 1.93-3.43]; p = 0.49). The operative time for PSPR was significantly less (30.3 [95% CI 16.3-44.3] min v. 67 [95% CI 43-91] min; p < 0.001), as were the operative costs. Recurrence (28.0% v. 36.8%; p = 0.53) and complication rates were equivalent. CONCLUSION: PSPR is a safe, efficient and effective approach to perineal proctosigmoidectomy. It is associated with surgical outcomes comparable to those of the Altemeier procedure, but with a significant reduction in operative time and cost.

To CT or not to CT? The influence of computed tomography on the diagnosis of appendicitis in obese pediatric patients.

BACKGROUND: Appendicitis is a common pediatric query. However, obesity often results in nondiagnostic ultrasounds and increased likelihood of abdominal computed tomography (CT). Concern regarding radiation exposure led the Canadian Association of Radiologists to recommend foregoing CT when ultrasounds are nondiagnostic and clinical suspicion is high. We evaluated this recommendation by quantifying the influence of CT on the diagnosis of pediatric appendicitis. METHODS: We performed a 2-year retrospective case series of children presenting with suspected appendicitis. We stratified patients by weight (obese v. nonobese) and pediatric appendicitis score (PAS) and examined how often they received abdominal CT, why they received it, and its influence on diagnosis. RESULTS: Of 223 patients (84 obese, 139 nonobese), 54 received CT. Obese patients received CTs more frequently than nonobese patients (29% v. 22%). The most common reason for CT was a nondiagnostic ultrasound (75% in obese, 80% in nonobese patients). Sixty-five percent of CTs obtained after nondiagnostic ultrasounds confirmed the initial diagnosis, but the rates were 80% and 50%, respectively, when only obese and only nonobese patients were considered. Obese patients were 4 times more likely to have a CT confirming their initial appendicitis diagnosis. CONCLUSION: Because obese patients are more likely than nonobese patients to have a CT that confirms appendicitis, when treating an obese pediatric patient with suspected appendicitis and a nondiagnostic ultrasound, surgeons with a high clinical suspicion should strongly consider foregoing CT and proceeding with treatment.

CONTEXTE: L'appendicite est un tableau fréquent en pédiatrie. Toutefois, l'obésité produit souvent des résultats non diagnostiques à l'échographie et accroît la probabilité de recours à la tomographie abdominale. L'inquiétude soulevée par l'exposition aux radiations a poussé l'Association canadienne des radiologistes à déconseiller la tomographie lorsque l'échographie se révèle non diagnostique et que les soupçons cliniques sont élevés. Nous avons évalué cette recommandation en quantifiant l'influence de la tomographie sur le diagnostic de l'appendicite chez l'enfant. MÉTHODES: Nous avons procédé à la revue rétrospective d'une série de cas pédiatriques d'appendicite soupçonnée sur une période de 2 ans. Nous avons stratifié les patients selon le poids (obèses c. non obèses) et selon le score diagnostique d'appendicite pédiatrique, puis examiné la fréquence à laquelle on recourait à la tomographie abdominale, sa justification et son influence sur le diagnostic. RÉSULTANTS: Sur 223 patients (84 obèses, 139 non obèses), 54 ont subi une tomographie. Les patients obèses ont été soumis à la tomographie plus souvent que les patients non obèses (29 % c. 22 %). La raison la plus fréquemment invoquée pour recourir à la tomographie était l'échographie non diagnostique (75 % chez les patients obèses, 80 % chez les patients non obèses). Soixante-cinq pour cent des tomographies obtenues après une échographie non diagnostique ont confirmé le diagnostic initial, mais les taux étaient de 80 % et de 50 % respectivement lorsqu'on analysait les groupes obèses et non obèses séparément. Les patients obèses étaient 4 fois plus susceptibles de voir leur diagnostic initial d'appendicite confirmé par la tomographie. CONCLUSION: Étant donné que les patients obèses sont plus susceptibles que les patients non obèses de subir une tomographie qui confirmerait une appendicite, face à un patient pédiatrique obèse chez qui l'on soupçonne une appendicite et dont les résultats à l'échographie sont non diagnostiques, les chirurgiens qui entretiennent des soupçons cliniques élevés devraient envisager fortement d'éviter la tomographie et de procéder au traitement.