Optimizing the consent process for emergent laparoscopic cholecystectomy using an interactive digital education platform: a randomized control trial.

BACKGROUND: Informed consent is essential for any surgery. The use of digital education platforms (DEPs) can enhance patient understanding of the consent discussion and is a method to standardize the consent process in elective, ambulatory settings. The use of DEP as an adjunct to standard verbal consent (SVC) has not been studied in an acute care setting. METHODS: We conducted a prospective randomized control trial with patients presenting to the emergency department of a tertiary care hospital with acute biliary pathology requiring a laparoscopic cholecystectomy (LC) between August 2021 and April 2023. Participants were randomized 1:1 to receive either a DEP module with SVC or SVC alone. Baseline procedure-specific knowledge and self-reported understanding of risks and benefits of LC were collected using a questionnaire. Primary outcome was immediate post-intervention knowledge assessed using a 21-question multiple choice questionnaire. Secondary outcomes were delayed procedure-specific knowledge and participants' satisfaction with the consent discussion. RESULTS: We recruited 79 participants and randomized them 1:1 into the intervention group (DEP + SVC, n = 40) and the control group (SVC, n = 39). Baseline demographics and baseline procedure-specific knowledge were similar between groups. The immediate post-intervention knowledge was significantly higher for participants in the intervention versus the control group with a Cohen's d effect size of 0.68 (85.2(10.6)% vs. 78.2(9.9)%; p = 0.004). Similarly, self-reported understanding of risks and benefits of LC was significantly greater for participants in the intervention versus the control group with a Cohen's effect size of 0.76 (68.5(16.4)% vs. 55.1(18.8)%; p = 0.001). For participants who completed the delayed post-intervention assessment (n = 29), there continued to be significantly higher retention of acquired knowledge in the intervention group with a Cohen's effect size of 0.61 (86.5(8.5)% vs. 79.8 (13.1)%; p = 0.024). There was no difference in participants' self-reported satisfaction with the consent discussion between groups (69.5(6.7)% vs. 67.2(7.7)%; p = 0.149). CONCLUSION: The addition of digital education platform to standard verbal consent significantly improves patient's early and delayed understanding of risks and benefits of LC in an acute care setting.

Predictors of Postoperative Liver Decompensation Events After Resection in Patients with Cirrhosis and Hepatocellular Carcinoma: A Population-Based Study.

BACKGROUND: Appropriate patient selection for liver resection in hepatocellular carcinoma (HCC) is critical to mitigation of major liver-related postoperative complications. Currently, no standard prognostic tool exists to predict the risk of postoperative liver decompensation events (POLDEs) after partial hepatectomy for patients with cirrhosis and HCC. This study aimed to identify independent preoperative predictors of POLDEs for future development of prognostic tools to improve surgical decision-making. METHODS: This population-based, retrospective cohort study investigated patients with cirrhosis and incident HCC between 2007 and 2017, identified using administrative health data from Ontario, Canada. The occurrence of a POLDE or death within 2 years after surgery was described. Multivariable Cox regression identified independent predictors of POLDE-free survival, as well as cause-specific hazards for POLDEs and death. RESULTS: Among 611 patients with cirrhosis and HCC who underwent liver resection, 160 (26.2%) experienced at least one POLDE, and 189 (30.9%) died within 2 years after surgery. Diabetes, cirrhosis etiology, major liver resection, and previous non-malignant decompensation were independent predictors of POLDE-free survival. Except for extent of resection, the same risk factors were associated with POLDEs in the cause-specific analysis. In contrast, only age and history of previous non-malignant decompensation were independent predictors of mortality. CONCLUSIONS: Among patients with cirrhosis undergoing resection for HCC, patient and disease-related factors are associated with POLDEs and POLDE-free survival. These factors can be used both to inform clinical practice and to advance the development of preoperative prognostic tools, which may lead to improved outcomes for this population.

Incidence, Timing, and Outcomes of Venous Thromboembolism in Patients Undergoing Surgery for Esophagogastric Cancer: A Population-Based Cohort Study.

BACKGROUND: Abdominal surgery and chemotherapy are well-established risk factors for venous thromboembolism (VTE) in patients with cancer, but their specific contribution in patients with esophageal and gastric cancer is unclear. We aim to quantify the risk of VTE, identify risk factors associated with VTE, and determine the association between VTE and survival in patients undergoing surgery for esophageal or gastric cancer. METHODS: A retrospective, population-based cohort study was conducted using linked administrative healthcare databases. We used the Ontario Cancer Registry to identify patients with esophageal or gastric cancer between January 1, 2007 and December 31, 2016 who underwent surgical resection. Incidence of first VTE event was identified using International Classification of Diseases 9 and 10 codes. VTE incidence was calculated at clinically relevant time points 180 days before and after surgery. Logistic regression was used to identify factors associated with VTE with odds ratios (OR) and 95% confidence intervals (CI) reported. Cox proportional hazards regression models were used to estimate associations between covariates and survival. Kaplan-Meier method was used to compare overall (OS) and cancer-specific survival (CSS) by VTE status. RESULTS: A total of 4894 patients had esophagectomy or gastrectomy, of which 8% (n = 383/4894) had VTE. VTE risk was 2.5% (n = 123/4894) 180 days before surgery, 2.8% (n = 138/4894) within 30 days of surgery, and 2.5% (n = 122/4894) from 31 to ≤ 180 days after surgery. Of the patients with VTE within 30 days of surgery, 34% (n = 47/138) were diagnosed after discharge from hospital. Receipt of preoperative chemotherapy was associated with VTE 180 days before surgery (odds ratio [OR] 3.84, 95% confidence interval [CI] 2.41, 6.11). Increased hospital length of stay (LOS) was associated with VTE 30 days after surgery (OR 1.08, 95% CI 1.02, 1.14, per week). Patients with VTE had inferior median OS and CSS (2.2 vs. 3.7 years; 2.3 vs. 4.4 years, respectively). In adjusted models VTE was associated with inferior OS (HR 1.36, 95% CI 1.13, 1.63) and CSS (HR 1.42, 95% CI 1.16, 1.75). CONCLUSIONS: The highest risk of VTE is within 30 days of surgery with one third of patients diagnosed after discharge from hospital. Longer hospital LOS and receipt of preoperative chemotherapy are associated with increased risk of VTE. VTE is an independent risk factor for inferior survival in patients with esophageal or gastric cancer.

Incidence and Risk Factors of Venous Thromboembolism Following Hepatectomy for Colorectal Metastases: A Population-Based Retrospective Cohort Study.

BACKGROUND: Incidence of venous thromboembolism (VTE) following hepatectomy for colorectal cancer (CRC) metastases is unclear. These patients may represent a vulnerable population due to increased tumour burden. We aim to identify the risk of VTE development in routine clinical practice among patients with resected CRC liver metastases, the associated risk factors, and its impact on survival. METHODS: We conducted a population-based retrospective cohort study of Ontario patients undergoing hepatectomy for CRC metastases between 2002 and 2009 using linked universal healthcare databases. Multivariable logistic regression was used to estimate the association between patient characteristics and VTE risk at 30 and 90-days after surgery. Cox proportional-hazards regression was used to estimate the association between VTE and adjusted cancer specific (CSS) and overall survival (OS). RESULTS: 1310 patients were included with a mean age of 63 ± 11. 62% were male. 51% had one metastatic deposit. Major hepatectomy occurred in 64%. VTE occurred in 4% within 90 days of liver resection. Only longer length of stay was associated with VTE development (OR 6.88 (2.57-18.43), p <0.001 for 15-21 days versus 0-7 days). 38% of VTEs were diagnosed after discharge, comprising 1.52% of the total cohort. VTE was not associated with inferior CSS or OS. CONCLUSIONS: Risk of VTE development in this population is similar to those undergoing hepatectomy for other indications, and to the risk following other cancer site resections where post-operative extended VTE prophylaxis is currently recommended. The number of VTEs occurring after discharge suggests there may be a role for extended VTE prophylaxis.

Surgical practice patterns and outcomes in T2 and T3 gallbladder cancer: a population-based study.

BACKGROUND: The extent of resection required in advanced gallbladder cancer is controversial. We aimed to describe the management and outcomes in patients with resected stage T2 and T3 gallbladder cancer. METHODS: In this population-based study, all T2 and T3 gallbladder cancer cases from Jan. 1, 2002, to Mar. 31, 2012, were identified from the Ontario Cancer Registry; pathology reports were linked and abstracted. The type of resection was classified as extended (cholecystectomy + liver resection, with or without bile duct resection) or simple (cholecystectomy only). We used Kaplan-Meier survival analysis to model time to death and evaluated factors associated with overall survival using the Cox proportional hazards regression model. RESULTS: A total of 370 patients were included, 232 with T2 disease and 138 with T3 disease. The proportions who underwent extended resection were 24.1% (56/232) and 37.0% (51/138), respectively. The unadjusted 5-year overall survival rates for simple and extended resection were 39.7% and 49.5%, respectively, for T2 disease (p = 0.03), and 13.5% and 22.8%, respectively, for T3 disease (p = 0.05). In adjusted analysis, extended resection significantly improved overall survival among patients with T2 disease (hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.30-0.97), whereas higher grade of differentiation, presence of lymphovascular invasion and positive lymph nodes led to worse survival. Extended resection was not associated with improved survival in the T3 group; however, in subgroup analysis stratified by lymph node status, a trend toward improved overall survival with extended resection was seen in node-negative patients (HR 0.20, 95% CI 0.03-1.06). CONCLUSION: Extended resection improved overall survival in T2 disease regardless of nodal status but appeared most beneficial in node-negative T3 disease. The finding that extended resection was offered only to a small proportion of eligible patients highlights the need for improved knowledge translation at national surgical meetings.

PATCH-DP: a single-arm phase II trial of intra-operative application of HEMOPATCH™ to the pancreatic stump to prevent post-operative pancreatic fistula following distal pancreatectomy.

BACKGROUND: Post-operative pancreatic fistula (POPF) is the most significant cause of morbidity following distal pancreatectomy. Hemopatch™ is a thin, bovine collagen-based hemostatic sealant. We hypothesized that application of Hemopatch™ to the pancreatic stump following distal pancreatectomy would decrease the incidence of clinically-significant POPF. METHODS: We conducted a prospective, single-arm, multicentre phase II study of application of Hemopatch™ to the pancreatic stump following distal pancreatectomy. The primary outcome was clinically-significant POPF within 90 days of surgery. A sample size of 52 patients was required to demonstrate a 50% relative reduction in Grade B/C POPF from a baseline incidence of 20%, with a type I error of 0.2 and power of 0.75. Secondary outcomes included incidence of POPF (all grades), 90-day mortality, 90-day morbidity, re-interventions, and length of stay. RESULTS: Adequate fixation Hemopatch™ to the pancreatic stump was successful in all cases. The rate of grade B/C POPF was 25% (95%CI: 14.0-39.0%). There was no significant difference in the incidence of grade B/C POPF compared to the historical baseline (p = 0.46). The 90-day incidence of Clavien-Dindo grade ≥3 complications was 26.9% (95%CI: 15.6-41.0%). CONCLUSION: The use of Hemopatch™ was not associated with a decreased incidence of clinically-significant POPF compared to historical rates. (NCT03410914).

Are patients truly informed? A retrospective chart review of the documentation of informed consent in laparoscopic cholecystectomy.

Background: Research on informed consent (IC) has traditionally focused on the documentation of the discussion with patients of potential complications. We sought to examine the completeness of documentation for all elements of IC for laparoscopic cholecystectomy (LC): potential complications, alternatives to LC and details of the procedure. Differences in the documentation of IC for elective and emergent LC were examined. Methods: A retrospective chart review of patients undergoing LC at our institution between 2015 and 2017 was performed. Completeness of documentation was defined as documentation of all 3 elements of IC in the clinic note, the operating room note or the consent form itself. Data were analyzed descriptively. We compared documention for emergent and elective cases as well as documentation by residents and attending physicians using t tests. Results: A total of 270 patients were included in the analysis. Only 5 (2%) had complete documentation of all elements of IC. Documentation of potential complications was noted in 232 cases (86%), of which 58 (25%) were elective and 174 (75%) were emergent. Details were noted in 28 (10%) cases, of which 21 (75%) were elective and 7 (25%) were emergent. Alternatives were documented the least frequently: they were documented in 23 cases (9%), of which 20 (87%) were elective and 3 (13%) were emergent. Residents performed better than attending physicians in documenting IC discussions in clinic notes and on consent forms, but not in operating room notes. Conclusion: Documentation of the elements of IC for LC was poor. Potential complications were the most frequently documented element of IC; alternatives and details were often omitted. Future studies comparing audiotaped IC conversations with the documentation of IC are warranted. The use of procedure-specific consent forms for LC may facilitate documentation.

Contexte: La recherche sur le consentement éclairé (CÉ) s'est longtemps intéressée surtout à la consignation du contenu des discussions avec les patients au sujet des complications potentielles. Nous avons voulu examiner l'exhaustivité de la consignation de tous les éléments du CÉ pour la cholécystectomie laparoscopique (CL) : complications potentielles, solutions de rechange à la CL et détails de l'intervention. Nous avons observé des différences dans la consignation des éléments du CÉ pour la CL urgente et non urgente. Méthodes: Nous avons procédé à un examen rétrospectif des dossiers de patients soumis à une CL dans notre établissement entre 2015 et 2017. La consignation au dossier était jugée complète lorsque les 3 éléments du CÉ étaient présents dans la note clinique, la note opératoire ou le formulaire de consentement lui-même. Nous avons effectué une analyse descriptive des données, et nous avons comparé la consignation des éléments pour les cas urgents et non urgents, effectuée par les résidents et les médecins traitants au moyen de tests t. Résultats: Au total, 270 patients ont été inclus dans l'analyse. Tous les éléments du CÉ étaient adéquatement consignés pour seulement 5 (2 %) d'entre eux. Les complications potentielles ont été consignées dans 232 cas (86 %), dont 58 (25 %) étaient non urgents et 174 (75 %) étaient urgents. Les détails de l'intervention ont été notés dans 28 cas (10 %), dont 21 (75 %) étaient non urgents et 7 (25 %) étaient urgents. Ce sont les solutions de rechange qui ont été le moins souvent consignées : elles ont été notées dans 23 cas (9 %), dont 20 (87 %) étaient non urgents et 3 (13 %) étaient urgents. Les résidents ont mieux fait que les médecins traitants pour ce qui est de consigner les discussions sur le CÉ dans les notes cliniques et les formulaires de CÉ, mais non dans les notes opératoires. Conclusion: La consignation des éléments du CÉ pour la CL a été faible. Les complications potentielles ont été l'élément du CÉ le plus souvent consigné au dossier; les solutions de rechange et les détails de l'intervention ont souvent été omis. Il faudra procéder à d'autres études pour comparer le contenu des discussions sur le CÉ enregistrées sur bande audio et sa consignation. L'utilisation de formulaires de CÉ spécifiques aux interventions pourrait faciliter la consignation de leurs éléments.

Competency-based education in general surgery: Are Canadian residents ready?

Summary: Competency-based education (CBE) is currently being implemented by the Royal College of Physicians and Surgeons of Canada across all residency programs. This shift away from time-based residency is proposed to be the answer to maximize training opportunity in the era of work hour restrictions and growing concerns regarding accountability in medical education. A Web-based survey was conducted to obtain feedback from Canadian general surgery residents on their experience and perception of competence within core procedures, as well as attitudes toward CBE. A total of 244 residents completed the survey. For most procedures, more than 50% of residents felt they could perform the procedure with no guidance after completing 11-30 cases. Generally, residents were welcoming of CBE; however, medium-sized programs reported some concerns regarding inadequate exposure to cases and risk of training less well-rounded surgeons. This is valuable resident feedback for programs to consider during the implementation process.

Appraisal of multivariable prognostic models for post-operative liver decompensation following partial hepatectomy: a systematic review.

BACKGROUND: Few reports have evaluated prognostic modelling studies of tools used for surgical decision-making. This systematic review aimed to describe and critically appraise studies that have developed or validated multivariable prognostic models for post-operative liver decompensation following partial hepatectomy. METHODS: This study was designed using the CHARMS checklist. Following a comprehensive literature search, two reviewers independently screened candidate references for inclusion and abstracted relevant study details. Qualitative assessment was performed using the PROBAST tool. RESULTS: We identified 36 prognostic modelling studies; 25 focused on development only, 3 developed and validated models, and 8 validated pre-existing models. None compared routine use of a prognostic model against standard clinical practice. Most studies used single-institution, retrospective cohort designs, conducted in Eastern populations. In total, 15 different outcome definitions for post-operative liver decompensation events were used. Statistical concerns surrounding model overfitting, performance assessment, and internal validation led to high risk of bias for all studies. CONCLUSIONS: Current prognostic models for post-operative liver decompensation following partial hepatectomy may not be valid for routine clinical use due to design and methodologic concerns. Landmark resources and reporting guidelines such as the TRIPOD statement may assist researchers, and additionally, model impact assessment studies represent opportunities for future research.

Perioperative blood transfusion and resection of colorectal cancer liver metastases: outcomes in routine clinical practice.

BACKGROUND: Prior work has shown associations between blood transfusion (BT) and inferior outcomes during resection for colorectal cancer liver metastases (CRLM). Herein, we describe short and long-term outcomes relating to perioperative BT in routine clinical practice. METHODS: All CRLM resections in Ontario, Canada from 2002 to 2009 were identified using the Ontario Cancer Registry. Log-binomial regression and Cox regression were used to explore factors associated with receipt of BT and the association of BT with 5-year cancer specific (CSS) and overall survival (OS), respectively. RESULTS: The study included 1310 patients; 31% (403/1310) had perioperative BT. Transfused patients had longer median length of stay (9 vs. 7 days, p < 0.001), higher 90-day mortality (9% vs. 1%, p < 0.001), greater 90-day readmission (28% vs. 16%, p < 0.001), and inferior 5-year CSS (41% vs. 48%, p = <0.001) and OS (38% vs. 47%, p < 0.001). Transfusion was independently associated with inferior CSS (HR = 1.35, 95% CI: 1.11-1.63) and OS (HR = 1.30, 95% CI: 1.10-1.53), however, excluding 90-day postoperative deaths showed these associations were no longer significant. CONCLUSION: Perioperative BT is common in patients undergoing resection of CRLM. While transfusion is associated with greater morbidity, mortality, and inferior survival, after excluding early postoperative deaths, BT does not appear to be independently associated with CSS or OS.

A Population-Based Cohort Study of Venous Thromboembolism Rates Following Surgery and During Adjuvant Chemotherapy in Patients With Colon Cancer.

BACKGROUND: There is an elevated risk of venous thromboembolism in patients treated for colon cancer. Postoperative venous thromboembolism has been studied previously, but no large study has compared the risks during different stages of treatment. OBJECTIVE: This study aimed to quantify and compare the risks of venous thromboembolism before surgery, after surgery, during adjuvant chemotherapy, and up to 365 days after surgery among patients with resected colon cancer. DESIGN: This is a population-based retrospective cohort study. SETTING: This study was conducted in a single-payer, universal health care setting (Ontario) between 2002 and 2008. PATIENTS: A total of 6806 patients with stage I to III colon cancer treated with surgical resection were included. INTERVENTIONS: Phases of treatment were evaluated, including preoperative, in-hospital, postoperative, during adjuvant chemotherapy, and 365 days postoperatively. MAIN OUTCOME MEASURES: Venous thromboembolism, as defined using diagnostic codes from administrative data sources, was the primary outcome measured. RESULTS: Of the 6806 patients included, 327 (5%) developed venous thromboembolism. Patients receiving adjuvant chemotherapy had a higher risk versus surgery-alone patients (6% vs 4%, p < 0.001). Of the 327 who developed venous thromboembolism, 32% (1.6% overall) were diagnosed during hospital admission and 13.5% (0.6% overall) were diagnosed between discharge and 30 days after surgery. The majority of venous thromboembolisms diagnosed in patients receiving adjuvant chemotherapy (53%, 3.1% of all patients receiving adjuvant chemotherapy) were diagnosed within 180 days of starting adjuvant chemotherapy. Venous thromboembolism was an independent risk factor for worse 5-year overall survival (HR, 1.65; 95% CI, 1.43-1.91; p < 0.001). LIMITATIONS: This study was limited by the potential for misclassification of venous thromboembolism and unknown compliance with prophylaxis recommendations. CONCLUSION: Patients who undergo treatment for stage I to III colon cancer are at considerable risk of developing venous thromboembolism. The risk is elevated in those who require adjuvant chemotherapy, and venous thromboembolism is associated with worse long-term outcomes. There may be a role of venous thromboembolism prophylaxis during all phases of treatment, including both after surgery and during adjuvant chemotherapy. See Video Abstract at http://links.lww.com/DCR/B123. UN ESTUDIO DE COHORTE POBLACIONAL DE LAS TASAS DE TROMBOEMBOLISMO VENOSO DESPUÉS DE CIRUGÍA Y DURANTE QUIMIOTERAPIA ADYUVANTE EN PACIENTES CON CÁNCER DE COLON: Existe un riesgo elevado de tromboembolismo venoso en pacientes tratados por cáncer de colon. El tromboembolismo venoso postoperatorio se ha estudiado previamente, pero ningún estudio grande ha comparado los riesgos durante las diferentes etapas del tratamiento.Cuantificar y comparar los riesgos de tromboembolismo venoso antes de la cirugía, después de la cirugía, durante quimioterapia adyuvante y hasta 365 días después de cirugía en pacientes con cáncer de colon resecado.Estudio retrospectivo de cohorte poblacional.Escenario de atención médica universal con pagador único (Ontario) entre 2002-2008.6,806 pacientes con cáncer de colon en estadio I-III tratados con resección quirúrgica.Fase de tratamiento, incluyendo preoperatorio, hospitalización, postoperatorio, durante quimioterapia adyuvante y 365 días después de la operación.Tromboembolismo venoso, tal como se define utilizando códigos de diagnóstico de fuentes de datos administrativos.Se incluyeron 6,806 pacientes, con 327 (5%) que desarrollaron tromboembolismo venoso. Los pacientes que recibieron quimioterapia adyuvante tuvieron un mayor riesgo en comparación con los pacientes con cirugía solamente (6% vs 4%, p <0.001). De los 327 que desarrollaron tromboembolismo venoso, 32% (1.6% en general) fueron diagnosticados durante el ingreso hospitalario y 13.5% (0.6% en general) fueron diagnosticados entre el alta y 30 días después de la cirugía. La mayoría de los tromboembolismos venosos diagnosticados en pacientes que recibieron quimioterapia adyuvante (53%, 3.1% de todos los pacientes con quimioterapia adyuvante) fueron diagnosticados dentro de los 180 días de comenzar la quimioterapia adyuvante. El tromboembolismo venoso fue un factor de riesgo independiente para una peor supervivencia general a 5 años (Hazard Ratio (cociente de riesgo) 1.65, IC 95% 1.43-1.91, p <0.001).Potencial de clasificación errónea del tromboembolismo venoso, cumplimiento desconocido de las recomendaciones de profilaxis.Los pacientes que se someten a tratamiento para el cáncer de colon en estadio I-III tienen un riesgo considerable de desarrollar tromboembolismo venoso. El riesgo es elevado en aquellos que requieren quimioterapia adyuvante y el tromboembolismo venoso se asocia con peores resultados a largo plazo. La profilaxis del tromboembolismo venoso puede desempeñar un papel durante todas las fases del tratamiento, incluyendo tanto el periodo posquirúrgico como durante la quimioterapia adyuvante. Consulte Video Resumen en http://links.lww.com/DCR/B123.

Predictors and Cumulative Frequency of Hepatocellular Carcinoma in High and Intermediate LI-RADS Lesions: A Cohort Study from a Canadian Academic Institution.

BACKGROUND: The frequency and predictors of hepatocellular carcinoma (HCC) within each liver imaging reporting and data system (LI-RADS) category remains unclear. We sought to estimate the cumulative frequency of HCC in LI-RADS observations of high/intermediate category and identify clinical/radiographic features associated with HCC. METHODS: Our diagnostic imaging database was searched for computed tomography/magnetic resonance imaging reports of patients with evidence of cirrhosis and liver observations. LI-RADS categories were determined by imaging review, while demographic and clinical outcomes were assigned by chart review. A composite outcome of clinical/radiographic confirmation of HCC was used. We used multivariable analysis to identify features associated with HCC, and competing risks regression to estimate the cumulative frequency of HCC in each category. RESULTS: Our search returned 95 patients with 137 observations (LR2 = 4, LR3 = 53, LR4 = 37, and LR5 = 43). On multivariable analysis, increasing age (hazard ratio [HR] 1.76 per 10 years, p = 0.049), washout (HR 5.34, p < 0.002), and increasing size (size < 10 mm reference, 10-20 mm, HR 3.93, p = 0.014; size > 20 mm, HR 21.69, p < 0.001) were associated with HCC. Median time to diagnosis was 6.13 months (interquartile range [IQR] 4.6-13.1), 4.7 months (IQR 2.5-14.5), and 3.6 months (IQR 1.9-6.6) for LR3, 4, and 5 category observations, respectively. The cumulative frequency of HCC was 59.8% in LR3, 84.62% in LR4, and 99.84% in LR5, at last follow-up. CONCLUSION: The frequency of HCC within each LI-RADS category reflects the intended purpose, intermediate probability for LR3, probable HCC for LR4, and definite HCC for LR5.

Palliative Care and Symptom Burden in the Last Year of Life: A Population-Based Study of Patients with Gastrointestinal Cancer.

INTRODUCTION: The symptom profile in cancer patients and the association between palliative care (PC) and symptoms has not been studied in the general population. We addressed these gaps in gastrointestinal (GI) cancer patients in the final year of life. METHODS: Patients dying of esophageal, gastric, colon, and anorectal cancers during 2003-2015 were identified. Symptom scores were recorded in the year before death using the Edmonton Symptom Assessment System (ESAS), which includes scores from 0 to 10 in nine domains. Symptom severity was categorized as none-mild (≤ 3) or moderate-severe (≥ 4-10). Adjusted associations between outpatient PC and moderate-severe ESAS scores were determined, and the effect of PC initiation on ESAS scores was estimated. RESULTS: The cohort included 11,242 patients who died (esophageal [17%], gastric [20%], colon [38%], and anorectal [26%] cancers). Fifty percent experienced moderate-severe scores in tiredness, lack of well-being, and lack of appetite earlier (weeks 18 to 12 before death), whereas 50% experienced moderate-severe scores in drowsiness, pain, and shortness of breath later (weeks 5 to 2 before death) in the disease course. Outpatient PC was associated with an increased likelihood of moderate-severe scores in all domains, with the highest score in pain (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.68-2.05). In PC-naïve patients with moderate-severe scores, initiation of outpatient PC was associated with a 1- to 3-point decrease in subsequent scores, with the greatest reductions in pain (OR - 1.91, 95% CI - 2.11 to - 1.70) and nausea (OR - 3.01, 95% CI - 3.31 to - 2.71). CONCLUSION: GI cancer patients experience high symptom burden in the final year of life. Outpatient PC initiation is associated with a decrease in symptoms.

Palliative Care is Associated with Reduced Aggressive End-of-Life Care in Patients with Gastrointestinal Cancer.

BACKGROUND: We examined the delivery of physician palliative care (PC) services and its association with aggressive end-of-life care (EOLC) in patients with gastrointestinal (GI) cancer in Ontario, Canada. METHODS: All patients with primary cause of death from esophageal, gastric, colon, and anorectal cancer from January 2003 to December 2013 were identified. PC services within 2 years of death were classified: (1) any PC; (2) timing of first PC (≤ 7, 8-90, 91-180, and 181-730 days before death); and (3) intensity of PC measured by number of days used (1st-25th, 26th-50th, 51st-75th, and 76th-100th percentiles). Aggressive EOLC was defined as any of the following: chemotherapy, emergency department visits, hospital or intensive care unit (ICU) admissions (all ≤ 30 days of death), and death in hospital and in the ICU; these were combined as a composite outcome (any aggressive EOLC). RESULTS: The cohort included 34,630 patients, of whom 74% had at least one PC service. Timing of the first PC service varied: ≤ 7 (12%), 8-90 (42%), 91-180 (16%), and 181-730 (30%) days before death. Compared with patients not receiving PC, any PC was associated with a reduction in any aggressive EOLC (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.74-0.76); this association was similar regardless of timing of the first PC service. The most dramatic reduction in aggressive EOLC occurred in patients who received the greatest number of days of PC (RR 0.65, 95% CI 0.63-0.67). CONCLUSIONS: The majority of patients received PC within 2 years of death. A larger number of days of PC was associated with a greater reduction in aggressive EOLC.

Assessing tools for management of noncolorectal nonneuroendocrine liver metastases: External validation of a prognostic model.

INTRODUCTION: Selection criteria and benefits for resection of noncolorectal, nonneuroendocrine liver metastases (NCNNELM) remain debated. A prognostic score was developed by the Association Française de Chirurgie (AFC) for patient selection, but not validated. We performed a geographic external validation of this score. METHODS: Patients with resected NCNNELM from six institutions (2000-2014) were assigned risk groups based on the AFC score. Discrimination was evaluated by visually inspecting separation of overall survival (OS) curves among risk categories. The slope of the continuous score on OS and hazard ratios for risk categories were examined. RESULTS: Of 165 patients, 53 (32.1%) were low-risk, 85 (51.5%) intermediate-risk, and 27 (16.4%) high-risk. The OS curves did not separate among risk groups: 5-year OS were 60.1% (low), 57.1% (intermediate), and 55.6% (high). The parameter estimate (0.02) indicated lower discrimination than in the AFC cohort. Hazard ratios of 1.05 (0.63 to 1.70) for low vs intermediate, 0.87 (0.46 to 1.64) for low vs high, and 0.83 (0.46 to 1.49) for intermediate vs. high, demonstrated lack of discrimination in OS among risk groups. CONCLUSION: While long-term survival is achievable, discrimination of the AFC score is not maintained in a geographic external cohort of resected NCNNELM. It is not generalizable to this external population.

High complication rate among patients undergoing appendectomy in Ontario: a population-based retrospective cohort study.

BACKGROUND: Appendectomy is a common emergency procedure. The risks have been reported in previous studies but often are limited to inpatient complications. The purpose of this study was to describe inpatient and outpatient rates of complications associated with appendectomy in a contemporary population-based cohort and explore factors associated with these complications. METHODS: We conducted a retrospective study using linked data for Ontario within Institute for Clinical Evaluative Sciences databases. Patients who underwent emergent appendectomy between 2009 and 2014 were included. The primary outcome was a complication (death, readmission, emergency department visit, lengthy [> 7 d] hospital stay, percutaneous abscess drainage, reoperation or 1 of the predefined complication codes) occurring within 30 days of surgery. We used modified Poisson regression to identify predictors of complications. RESULTS: A total of 50 369 patients underwent emergent appendectomy over the study period, of whom 16 953 (33.7%) had a perforated appendix. Overall, 14 451 patients (28.7%) (8428 [25.2%] in the nonperforated group and 6023 [35.5%] in the perforated group) had at least 1 complication. The most common complication was an emergency department visit (7942 patients [15.8%]), followed by surgical site infection (4792 [9.5%]). Increasing age, female sex, rural residence, perforation status, daytime surgery and open surgical technique were associated with increased risk of complications. CONCLUSION: We found a higher rate of complications after appendectomy than previously reported. The most common complication was presentation to the emergency department. Our definition of complications is more inclusive than in previous studies and provides a deeper understanding of complications after appendectomy.

CONTEXTE: L'appendicectomie est une intervention urgente qui est courante. Les risques qui y sont associés ont déjà fait l'objet d'études, mais se limitent souvent aux complications perhospitalières. Cette étude avait pour but de décrire les taux de complications chez les patients durant et après leur hospitalisation pour appendicectomie dans une cohorte contemporaine basée dans la population et d'explorer les facteurs associés à ces complications. MÉTHODES: Nous avons procédé à une étude rétrospective à partir des données reliées des bases de données de l'Institute for Clinical Evaluative Sciences pour l'Ontario. Les patients soumis à une appendicectomie urgente entre 2009 et 2014 ont été inclus. Le paramètre principal était la survenue d'une complication (décès, réadmission, consultation aux urgences, séjour hospitalier prolongé [> 7 j], drainage d'abcès percutané, réintervention ou l'un des codes de complications prédéfinis) dans les 30 jours suivant la chirurgie. Nous avons utilisé la régression de Poisson pour identifier les facteurs prédicteurs de complications. RÉSULTATS: En tout, 50 369 patients ont subi une appendicectomie urgente au cours de la période de l'étude, dont 16 953 (33,7 %) présentaient un appendice perforé. Globalement, 14 451 patients (28,7 %) (8 428 [25,2 %] dans le groupe ayant l'appendice non perforé et 6 023 [35,5 %] dans le groupe ayant l'appendice perforé) ont eu au moins une complication. La complication la plus fréquente a été une consultation aux urgences (7942 patients [15,8 %]), suivie de l'infection du site opératoire (4792 [9,5 %]). L'âge avancé, le fait d'être de sexe féminin, de vivre en milieu rural, un appendice perforé, la chirurgie effectuée durant le jour et la technique chirurgicale ouverte ont tous été associés à un risque accru de complications. CONCLUSION: Nous avons observé un taux de complications post-appendicectomie plus élevé comparativement aux rapports précédents. La complication la plus fréquente était la consultation aux urgences. Notre définition du terme complications est plus inclusive que celle des précédentes études et permet une compréhension plus approfondie des complications post-appendicectomie.

Management of stage III colon cancer in the elderly: Practice patterns and outcomes in the general population.

BACKGROUND: Clinical trials have established surgical resection and adjuvant chemotherapy (ACT) as the standard management for stage III colon cancer; however, the extent to which these results apply to elderly patients in routine practice is unclear. This article describes the management and outcomes of elderly patients with stage III colon cancer. METHODS: All cases of surgically resected colon cancer from 2002 to 2008 were identified with the population-based Ontario Cancer Registry. Pathology reports were obtained for a random sample (25% of all cases); those with stage III disease constituted the study population. The utilization of ACT, cancer-specific survival (CSS), and overall survival (OS) in elderly patients (≥70 years) and nonelderly patients (<70 years) were compared. RESULTS: The study population included 2920 patients, and 1521 (52%) were elderly. The 30- and 90-day mortality rates increased with advanced age: <70 years, 2% and 5%; 70 to 74 years, 3% and 7%; 75 to 79 years, 5% and 8%, and ≥80 years, 9% and 16% (P < .001). ACT was delivered to 48% of elderly patients and to 81% of younger patients (P < .001). Factors independently associated with ACT utilization among the elderly were a younger age (P < .001), male sex (P = .041), and no comorbidities (P = .001). Among elderly patients, ACT was associated with improved CSS (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.60-0.88) and OS (HR, 0.71; 95% CI, 0.60-0.83); however, the magnitude of the benefit was smaller for elderly patients than younger patients (HR for CSS, 0.53; 95% CI, 0.42-0.67; HR for OS 0.56; 95% CI, 0.45-0.69). CONCLUSIONS: Half of elderly patients with stage III colon cancer do not receive ACT. Although the effect size is smaller than that in younger patients, ACT is associated with improved long-term survival. Cancer 2017;123:2840-49. © 2017 American Cancer Society.

Utilization of pre-operative imaging for colon cancer: A population-based study.

OBJECTIVE: To assess the use of pre-operative imaging for colon cancer and to identify factors associated with utilization in routine clinical practice. METHODS: This population-based, retrospective cohort study used a random sample of 25% of colon cancer patients treated with surgery in the province of Ontario (2002-2008). Pre-operative imaging (<16 weeks from surgery) of the chest, abdomen-pelvis was identified. Modified poisson regression was used to analyze factors associated with practice patterns. RESULTS: Of the 7,249 included patients, 48% had pre-operative imaging (CT abdomen and imaging of the chest) in keeping with guideline recommendations. The rate of guideline concordant pre-operative imaging increased over time: 64% in the most recent study period (2006-2008) versus 31% (2002-2004); P < 0.001. Variables associated with use of chest imaging: Age, co-morbidity, surgeon volume, and geographic region; no association with gender, hospital volume, or socio-economic status. Variables associated with use of abdomen imaging: Hospital volume and geographic region; no association with age, gender, comorbidity, socio-economic status, or surgeon volume. CONCLUSION: In clinical practice, the majority of patients were not receiving pre-operative imaging that was in line with clinical practice guidelines; however, use increased over time indicating a possible association with dissemination of clinical practice guidelines. J. Surg. Oncol. 2017;115:202-207. © 2016 Wiley Periodicals, Inc.

The Final 30 Days of Life: A Study of Patients With Gastrointestinal Cancer in Ontario, Canada.

BACKGROUND: Studies have reported overly aggressive end-of-life care (EOLC) in many cancers. We investigate trends in, and factors associated with, aggressive EOLC among patients who died of gastrointestinal (GI) cancers in Ontario, Canada. METHODS: All patients with primary cause of death from esophageal, gastric, colon, and anorectal cancer from January 2003 to December 2013 were identified through the Ontario Cancer Registry, and information was collected from linked databases. Outcomes representing aggressive EOLC were assessed: administration of chemotherapy, any emergency department (ED) visits, hospital admissions, intensive care unit (ICU) admissions (all within 30 days of death), death in hospital and in ICU, and a composite outcome representing any aggressive EOLC. Temporal trends were analyzed using the Cochran-Armitage test. RESULTS: There were 34 630 patients in the cohort: 43% colon, 26% anorectal, 19% gastric, and 12% esophageal cancers. Aggressive EOLC was delivered to 65%, with a significantly decreasing trend from 64.8% in 2003 to 62.5% in 2013 ( P = .001). Utilization of specific elements of aggressive EOLC included 8% chemotherapy, 46% ED visits, 49% hospital admissions, 6% ICU admissions, 45% death in hospital, and 5% death in ICU. Trends over the study period showed that ED visits (from 43% to 46.9%; P = .0001) and death in ICU (from 3.7% to 4.9%; P = .04) significantly increased; hospital admissions (from 48.9% to 47.8%; P = .02) and death in hospital (from 46.6% to 38.9%; P < .0001) significantly decreased. CONCLUSIONS: Two-thirds of patients with GI cancer had aggressive EOLC in the last 30 days of life.

Simultaneous resection of primary colorectal cancer and synchronous liver metastases: a population-based study.

BACKGROUND: Simultaneous resection of primary colorectal cancer (CRC) and synchronous liver metastases (LM) is gaining interest. We describe management and outcomes of patients undergoing simultaneous resection in the general population. METHODS: All patients with CRC who underwent surgical resection of LM between 2002 and 2009 were identified using the population-based Ontario Cancer Registry and linked electronic treatment records. Synchronous disease was defined as having resection of CRCLM within 12 weeks of surgery for the primary tumour. RESULTS: During the study period, 1310 patients underwent resection of CRCLM. Of these, 226 (17%) patients had synchronous disease; 100 (44%) had a simultaneous resection and 126 (56%) had a staged resection. For the simultaneous and the staged groups, the mean number of liver lesions resected was 1.6 and 2.3, respectively (p < 0.001); the mean size of the largest lesion was 3.1 and 4.8 cm, respectively (p < 0.001); and the major hepatic resection rate was 21% and 79%, respectively (p < 0.001). Postoperative mortality for simultaneous cases at 90 days was less than 5%. Five-year overall survival and cancer-specific survival for patients with simultaneous resection was 36% (95% confidence interval [CI] 26%-45%) and 37% (95% CI 25%-50%), respectively. Simultaneous resections are common in the general population. A more conservative approach is being adopted for simultaneous resections by limiting the extent of liver resection. Postoperative mortality and long-term survival in this patient population is similar to that reported in other contemporary series. CONCLUSION: Compared with a staged approach, patients undergoing simultaneous resections had fewer and smaller liver metastases and underwent less aggressive resections. One-third of these patients achieved long-term survival.

CONTEXTE: La résection simultanée des cancers colorectaux primitifs et des métastases hépatiques synchrones suscitent de plus en plus d'intérêt. Nous décrivons la prise en charge et les résultats de patients de la population générale ayant subi une résection simultanée. MÉTHODES: Tous les patients atteints d'un cancer colorectal ayant bénéficié d'une résection chirurgicale des métastases hépatiques entre 2002 et 2009 ont été identifiés au moyen du Registre des cas de cancer de l'Ontario en population générale et des dossiers électroniques associés sur le traitement. La maladie synchrone a été définie comme le fait d'avoir subi une chirurgie de résection des métastases hépatiques du cancer colorectal dans les 12 semaines de la chirurgie de la tumeur primitive. RÉSULTATS: Pendant la période de l'étude, 1310 patients ont subi une résection des métastases hépatiques du cancer colorectal. Sur ce nombre, 226 (17 %) patients présentaient une maladie synchrone; 100 (44 %) patients ont subi une résection simultanée et 126 (56 %) patients ont subi une résection en 2 temps. Dans les groupes des résections simultanées et des résections en 2 temps, le nombre moyen de lésions hépatiques réséquées était de 1,6 et de 2,3, respectivement (p < 0,001); la taille moyenne de la lésion la plus importante était de 3,1 et de 4,8 cm, respectivement (p < 0,001) et le taux de résection hépatique majeure était de 21 % et de 79 %, respectivement (p < 0,001). La mortalité postopératoire après résection simultanée à 90 jours était inférieure à 5 %. La survie globale à 5 ans et la survie par cause des patients avec résection simultanée étaient de 36 % (intervalle de confiance [IC] de 95 %, 26 %-45 %) et de 37 % (IC 95 %, 25 %-50 %), respectivement. Les résections simultanées sont courantes au sein de la population générale. On commence à adopter une approche plus conservatrice pour les résections simultanées en limitant l'étendue de la résection hépatique. La mortalité postopératoire et la survie à long terme de cette population de patients sont semblables à celles signalées dans d'autres séries récentes. CONCLUSION: Comparativement à l'approche en 2 temps, les patients avec résections simultanées présentaient moins de métastases hépatiques et des métastases de plus petite taille, et les résections pratiquées étaient moins agressives. Le tiers de ces patients ont obtenu une survie à long terme.