Anand Govindarajan

Introduction of surgical safety checklists in Ontario, Canada.

BACKGROUND Evidence from observational studies that the use of surgical safety checklists results in striking improvements in surgical outcomes led to the rapid adoption of such checklists worldwide. However, the effect of mandatory adoption of surgical safety checklists is unclear. A policy encouraging the universal adoption of checklists by hospitals in Ontario, Canada, provided a natural experiment to assess the effectiveness of checklists in typical practice settings. METHODS We surveyed all acute care hospitals in Ontario to determine when surgical safety checklists were adopted. Using administrative health data, we compared operative mortality, rate of surgical complications, length of hospital stay, and rates of hospital readmission and emergency department visits within 30 days after discharge among patients undergoing a variety of surgical procedures before and after adoption of a checklist. RESULTS During 3-month periods before and after adoption of a surgical safety checklist, a total of 101 hospitals performed 109,341 and 106,370 procedures, respectively. The adjusted risk of death during a hospital stay or within 30 days after surgery was 0.71% (95% confidence interval [CI], 0.66 to 0.76) before implementation of a surgical checklist and 0.65% (95% CI, 0.60 to 0.70) afterward (odds ratio, 0.91; 95% CI, 0.80 to 1.03; P=0.13). The adjusted risk of surgical complications was 3.86% (95% CI, 3.76 to 3.96) before implementation and 3.82% (95% CI, 3.71 to 3.92) afterward (odds ratio, 0.97; 95% CI, 0.90 to 1.03; P=0.29). CONCLUSIONS Implementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications. (Funded by the Canadian Institutes of Health Research.).

Challenging the Feasibility and Clinical Significance of Current Guidelines on Lymph Node Examination in Rectal Cancer in the Era of Neoadjuvant Therapy

PURPOSE We sought to examine the feasibility and clinical significance of current guidelines on nodal assessment in patients with rectal cancer (RC) treated with neoadjuvant radiation. METHODS All patients with RC treated with curative surgery from 1991 to 2003 were included. Number of lymph nodes (LNs) assessed was compared between patients who received neoadjuvant therapy and surgery (NEO) and patients who underwent surgery alone (SURG). Impact of node retrieval on node positivity and disease-specific survival (DSS) in NEO patients was assessed. RESULTS In total, 708 patients were identified, of whom 429 (61%) were in the NEO group. These patients had significantly fewer nodes assessed than SURG patients (unadjusted mean, 10.8 v 15.5; adjusted mean difference, -5.0 nodes; P < .001). In the NEO group, 63% of patients had fewer than 12 nodes retrieved (P < .001 v SURG). The proportion of patients diagnosed with node-positive disease in the NEO group was significantly and monotonically associated with the number of lymph nodes retrieved, with no plateau in the relationship. Fewer nodes retrieved was not associated with inferior DSS. CONCLUSION In a tertiary cancer center, the 12-LN threshold was not relevant and often not achievable in patients with RC treated with neoadjuvant therapy. Lower LN count after neoadjuvant treatment was not associated with understaging or inferior survival. Although we support the critical importance of careful pathologic examination and adequate nodal staging, we challenge the relevance of LN count both in clinical practice and as a quality indicator in RC.

Surgical treatment of hepatic colorectal metastasis: evolving role in the setting of improving systemic therapies and ablative treatments in the 21st century.

Liver resection has clearly been established as the standard treatment for resectable colorectal liver metastases. This article will review the expanding role for hepatectomy in this disease. Faster and safer hepatectomies are allowing combined resections of the primary cancer and synchronous hepatic metastases. Effective neoadjuvant chemotherapy, as well as increasing data demonstrating effectiveness and safety of combined hepatectomy and ablative therapies, have further expanded the pool of patients now selected for resection. The end result is that increasing numbers of patients are undergoing acceptably aggressive surgical therapies with extension of life and possible cure. Successful multimodality therapies are also now allowing for long-term survival even in patients not cured of cancer. The prolonged survival of most patients treated by hepatectomy has allowed a long-term analysis of the patterns of recurrence, which emphasize the importance of controlling liver disease for prolongation of life. These improvements in treatments for hepatic metastases have come with a precipitous escalation of the costs of care. This will likely require that future clinical trials and algorithms of care not only be based on cancer outcome data but also on value analysis of treatment and follow-up regimens.

Outcomes of Daytime Procedures Performed by Attending Surgeons after Night Work.

BACKGROUND Sleep loss in attending physicians has an unclear effect on patient outcomes. In this study, we examined the effect of medical care provided by physicians after midnight on the outcomes of their scheduled elective procedures performed during the day. METHODS We conducted a population-based, retrospective, matched-cohort study in Ontario, Canada. Patients undergoing 1 of 12 elective daytime procedures performed by a physician who had treated patients from midnight to 7 a.m. were matched in a 1:1 ratio to patients undergoing the same procedure by the same physician on a day when the physician had not treated patients after midnight. Outcomes included death, readmission, complications, length of stay, and procedure duration. We used generalized estimating equations to compare outcomes between patient groups. RESULTS We included 38,978 patients, treated by 1448 physicians, in the study, of whom 40.6% were treated at an academic center. We found no significant difference in the primary outcome (death, readmission, or complication) between patients who underwent a daytime procedure performed by a physician who had provided patient care after midnight and those who underwent a procedure performed by a physician who had not treated patients after midnight (22.2% and 22.4%, respectively; P=0.66; adjusted odds ratio, 0.99; 95% confidence interval, 0.95 to 1.03). We also found no significant difference in outcomes after stratification for academic versus nonacademic center, physicians age, or type of procedure. Secondary analyses revealed no significant difference between patient groups in length of stay or procedure duration. CONCLUSIONS Overall, the risks of adverse outcomes of elective daytime procedures were similar whether or not the physician had provided medical services the previous night. (Funded by the University of Toronto Deans Fund and others.).

Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery

BACKGROUND The aim of this study was to examine whether midline, paramedian, or transverse incisions offer potential advantages for abdominal surgery. DATA SOURCES We searched MEDLINE, Embase, Web of Science, and The Cochrane Central Register of Controlled Trials from 1966 to 2009 for randomized controlled trials comparing incision choice. METHODS We systematically assessed trials for eligibility and validity and extracted data in duplicate. We pooled data using a random-effects model. RESULTS Twenty-four studies were included. Transverse incisions required less narcotics than midline incisions (weighted mean difference = 23.4 mg morphine; 95% confidence interval [CI], 6.9 to 39.9) and resulted in a smaller change in the forced expiratory volume in 1 second on postoperative day 1 (weighted mean difference = -6.94%; 95% CI, -10.74 to -3.13). Midline incisions resulted in higher hernia rates compared with both transverse incisions (relative risk = 1.77; 95% CI, 1.09 to 2.87) and paramedian incisions (relative risk = 3.41; 95% CI, 1.02 to 11.45). CONCLUSIONS Both transverse and paramedian incisions are associated with a lower hernia rate than midline incisions and should be considered when exposure is equivalent.

Predictive markers of colorectal cancer liver metastases

Liver metastases are the most common site of distant failure after curative resection of colorectal cancer and a source of significant cancer-related morbidity and mortality. Currently, imaging and conventional histopathologic features, such as T-stage and N-stage, are used by clinicians to inform prognosis and guide adjuvant treatment to reduce the risk of developing distant metastases. However, these tools only have a moderate ability to predict the development of liver metastases. Novel methods, including the detection of circulating tumor cells and carcinoembryonic antigens in serum, have been developed, and their prognostic and predictive characteristics have been assessed. In addition, several molecular and genetic markers in the primary tumor have been studied. Unfortunately, these studies are often small and their results have been mixed, yielding no consistent sets of externally validated predictors of colorectal liver metastases. For widespread clinical relevance, future tests need to be independently carried out on large independent patient samples.

Impact of colonoscopically missed cancers on patient outcomes.

404 Background: There is increasing recognition of the potential for cancers to be missed on colonoscopy, but little is known about their outcomes. The objective of this study was to evaluate the outcomes of missed cancers relative to those detected by colonoscopy. Methods: We conducted a retrospective population-based cohort study, including all patients diagnosed with colorectal cancer (CRC) in Ontario, Canada from 2003-2009, who had undergone a colonoscopy within 36 months prior to diagnosis. Using previously defined time windows, we defined detected cancers as those diagnosed within 6 months of index colonoscopy and missed cancers as those diagnosed between 6 and 36 months after index colonoscopy. Patient and tumor factors were recorded as covariates. The primary outcome was overall survival, with secondary outcomes of resection rate, emergency presentation, and surgical complication rate. Logistic regression was used to analyze binary outcomes and Kaplan-Meier and Cox regression analyses were used fo...

W1668 The use of Intraoperative Ablation Extends the Limits of Potentially Curative Treatment for Recurrent Colorectal Liver Metastases

S A T A b st ra ct s or 16% of all the patients experienced intraoperative blood loss of more than 1500ml. During operation, 16 patients (7%) received red cell blood transfusion. Two patients (0.9%) were returned to the operating room for postoperative hemorrhage. Univariate analysis identified body mass index (BMI, p=0.001), tumor size (p=0.002), resected liver volume (p<0.001), serum total bilirubin (p¬=0.053), serum prothrombin time (p=0.044), serum glutamate pyruvate transaminase (p=0.041), major hepatectomy (p<0.001), wide incision with right thoracotomy (p=0.085), and additional operative procedure (p=0.034) as risk factors for massive intraoperative blood loss; multivariate analysis identified major hepatectomy (p<0.001) and BMI (p=0.005) as independent risk factors of blood loss of more than 1500 ml. Conclusions: Autologous blood storage might be indicated in patients with these predictive factors. Laparoscopic hepatectomy should not be considered in these patients, because of increased intraoperative blood loss.