Erin D. Kennedy

Risk of small bowel obstruction after the ileal pouch-anal anastomosis.

ObjectiveTo determine the incidence of small bowel obstruction (SBO), to identify risk factors for its development, and to determine the most common sites of adhesions causing SBO in patients undergoing ileal pouch–anal anastomosis (IPAA). MethodsAll patients undergoing IPAA at Mount Sinai Hospital were included. Data were obtained from the institution’s database, patient charts, and a mailed questionnaire. SBO was based on clinical, radiologic, and surgical findings. Early SBO was defined as a hospital stay greater than 10 or 14 days because of delayed bowel function, or need for reoperation or readmission for SBO within 30 days. All patients readmitted after 30 days with a discharge diagnosis of SBO were considered to have late SBO. ResultsBetween 1981 and 1999, 1,178 patients underwent IPAA (664 men, 514 women; mean age 40.7 years). A total of 351 episodes of SBO were documented in 272 (23%) patients during a mean follow-up of 8.7 years (mean 1.29 episodes/patient). Fifty-four patients had more than one SBO. One hundred fifty-four (44%) of the SBOs occurred in the first 30 days; 197 (56%) were late SBOs. The cumulative risk of SBO was 8.7% at 30 days, 18.1% at 1 year, 26.7% at 5 years, and 31.4% at 10 years. The need for surgery for SBO was 0.8% at 30 days, 2.7% at 1 year, 6.7% at 5 years, and 7.5% at 10 years. In patients requiring laparotomy, the obstruction was most commonly due to pelvic adhesions (32%), followed by adhesions at the ileostomy closure site (21%). A multivariate analysis showed that when only late SBOs were considered, performance of a diverting ileostomy and pouch reconstruction both led to a significantly higher risk of SBO. ConclusionsThe risk of SBO after IPAA is high, although most do not require surgical intervention. Thus, strategies that reduce the risk of adhesions are warranted in this group of patients to improve patient outcome and decrease healthcare costs.

Pregnancy, Delivery, and Pouch Function After Ileal Pouch-Anal Anastomosis for Ulcerative Colitis

AbstractPURPOSE: This study was designed to evaluate the pregnancies, method of delivery, and functional results of females with chronic ulcerative colitis who have an ileal pouch-anal anastomosis. METHODS: A mailed questionnaire was sent to all females with an ileal pouch-anal anastomosis for chronic ulcerative colitis. Information on the pregnancy, method of delivery, and outcome was collected. Those females who had a successful pregnancy and delivery were contacted by telephone to clarify results and determine pouch functional results. Other clinical information was obtained from the Mount Sinai Hospital Inflammatory Bowel Disease database. RESULTS: Thirty-eight subjects had 67 pregnancies. Of these, 29 subjects had 49 deliveries. There were 25 vaginal deliveries and 24 cesarean sections. There were two pouch-related complications during the pregnancies and four pouch-related complications postpartum. All were treated nonoperatively. Stool frequency and day and night incontinence were increased during pregnancy in most subjects, but after delivery, prepregnancy function was restored in 24 (83 percent) of them. Five subjects (17 percent) had some degree of permanent deterioration in pouch function. Of these, three had vaginal deliveries, and two had cesarean sections. Multiple births and birth weight were not found to adversely affect subsequent pouch function. CONCLUSION: Pregnancy is safe in females with ileal pouch-anal anastomosis. Functional results are altered almost exclusively during the third trimester, but pouch function promptly returns to prepregnancy status in most females. A small proportion of females have long-term disturbances in function, but these are not related to the method of delivery. Thus, the method of delivery should be dictated by obstetric considerations.

Increased Experience and Surgical Technique Lead to Improved Outcome After Ileal Pouch-Anal Anastomosis: A Population-Based Study

PurposeThis study was designed to determine whether changes in length of stay and 30-day readmission, reoperation, and excision rates for the ileal pouch-anal anastomosis occurred over time and with changes in surgical technique and hospital volume.MethodsUsing three population-based administrative databases, data on all ileal pouch-anal anastomoses performed in the province of Ontario between January 1992 and June 1998 were obtained. The effect of age, gender, stage of the procedure, year of surgery, and hospital volume were examined for their effect on length of stay and readmission, reoperation, and excision rates.ResultsThere were 1,285 ileal pouch-anal anastomoses performed in 58 hospitals. There was a significant decrease in length of stay and reoperation and excision rates but a concommitant increase in readmission rate during the study period. Patients younger than aged 40 years had a significantly lower length of stay and excision rate. Patients who had a two-stage procedure had a shorter length of stay, readmission, and reoperative rate compared with those having a three-stage procedure. Hospital volume was a significant predictor of need for reoperation and excision with both low-volume and medium-volume hospitals having significantly higher rates than high-volume hospitals.ConclusionsOutcome after ileal pouch-anal anastomosis has improved. It is significantly better in patients younger than aged 40 years, having a two-stage procedure, and where surgery is performed at high-volume hospitals. It is likely that both modifications in surgical technique and surgical experience have led to improvements in clinical outcome after ileal pouch-anal anastomosis.

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.).

Outcomes research in surgery.

Abstract. The phrase “outcomes studies” is usually used to describe those studies where outcome is assessed in large cohorts of patients, often using data from administrative databases. They are used to determine the role and impact of variations in the structure and process of health care delivery play in routine practice. Optimally, outcome should be assessed in terms of measures that are important to patients (e.g., quality of life). More often, clinically relevant outcome measures are lacking, and outcome is measured in terms of mortality, morbidity, and length of hospital stay. Although the outcomes movement continues to expand and much valuable information can be learned from this type of study, there are limitations. These studies are essentially observational and most often are performed using databases set up for other purposes. Thus data may be incomplete and incorrect. Moreover, they cannot assess the impact of patient preferences on outcome. The term outcomes studies has also been applied to small area variation and volume outcome studies.

Patient decision aids for cancer treatment: are there any alternatives?

Although patient decision aids (pDAs) are effective, widespread use of pDAs for cancer treatment has not been achieved. The objectives of this study were to perform a systematic review to identify alternate types of decision support interventions (DSIs) for cancer treatment and a meta‐analysis to compare the effectiveness of these DSIs to pDAs.

Azathioprine or Ileocolic Resection for Steroid-Dependent Terminal Ileal Crohn’s Disease? A Markov Analysis

INTRODUCTIONThe objective of this study was to determine whether initial azathioprine therapy, followed by ileocolic resection if azathioprine fails, or initial ileocolic resection without a trial of azathioprine is the preferred treatment strategy in steroid-dependent, terminal ileal Crohn’s disease.METHODSA Markov, decision analytic model was developed to simulate a 36-month course for a patient with steroid-dependent, terminal ileal Crohn’s disease who would initially take azathioprine or have ileocolic resection. Clinically important outcomes in the model included side effects and effectiveness of azathioprine and postoperative complications, mortality, and recurrence following ileocolic resection. The probabilities and utilities for these variables were derived from previously published studies.RESULTSInitial azathioprine therapy offered a relatively small benefit of 0.45 quality-adjusted life-months over initial ileocolic resection. The model was sensitive to utility for being symptom-free on azathioprine and utility for being symptom-free postoperatively.CONCLUSIONSInitial azathioprine therapy and initial ileocolic resection are both reasonable treatment strategies in this setting. The preferred treatment strategy is highly dependent on the quality of life that can be achieved with each treatment option. Therefore, individual response and symptom control with each treatment must be strongly considered in this treatment decision.

The prognostic value of grade of regression and oncocytic change in rectal adenocarcinoma treated with neo-adjuvant chemoradiotherapy

Pathological staging and regression grading may affect the clinical outcome in rectal carcinoma patients treated with neoadjuvant chemoradiation (NACRT). Oncocytic change (OC) has also been described in the residual tumor. This study assesses the correlation of degree of pathological response and OC with clinical outcome.

Using patient and physician perspectives to develop a shared decision-making framework for colorectal cancer

BackgroundColorectal cancer is the third leading cause of death from cancer worldwide with over 900,000 diagnoses and 639,000 deaths each year. Although shared decision making is broadly advocated as a mechanism by which to achieve patient-centred care, there has been little investigation of patient and physician shared decision-making preferences and practices or the outcomes associated with shared decision making in the context of colorectal cancer.AimThe aim of this study is to determine patient and physician attitudes towards the use of shared decision making in the setting of colorectal cancer.MethodsStandard principles of qualitative research will be used to sample and interview 20 colorectal cancer patients in each of three tertiary care hospitals (n = 60) and 15 surgeons, radiation oncologists, and medical oncologists (n = 45) affiliated with cancer centres. The interview questions will be guided by a conceptual framework defining patient and physician factors that influence the shared decision-making process and associated outcomes in the setting of colorectal cancer. An inductive, grounded approach will be used by two investigators to independently analyze the interview transcripts. These investigators will meet to compare and achieve consensus on themes that will be tabulated to compare barriers, enablers, and outcomes of shared decision making by patient, physician, and contextual factors.DiscussionThis study is the first to examine both patient and physician perspectives on the use of shared decision making for colorectal cancer in North America or elsewhere. It will provide a framework that can be used to describe the shared decision-making process and its outcomes, and evaluate strategies to facilitate this process for patients with colorectal cancer.

Development and Implementation of a Synoptic MRI Report for Preoperative Staging of Rectal Cancer on a Population-Based Level

BACKGROUND: Colorectal cancer physician champions across the province of Ontario, Canada, reported significant concern about appropriate selection of patients for preoperative chemoradiotherapy because of perceived variation in the completeness and consistency of MRI reports. OBJECTIVE: The purpose of this work was to develop, pilot test, and implement a synoptic MRI report for preoperative staging of rectal cancer. DESIGN: This was an integrated knowledge translation project. SETTINGS: This study was conducted in Ontario, Canada. PATIENTS: Surgeons, radiologists, radiation oncologists, medical oncologists, and pathologists treating patients with rectal cancer were included in this study. INTERVENTIONS: A multifaceted knowledge translation strategy was used to develop, pilot test, and implement a synoptic MRI report. This strategy included physician champions, audit and feedback, assessment of barriers, and tailoring to the local context. A radiology webinar was conducted to pilot test the synoptic MRI report. MAIN OUTCOME MEASURES: Seventy-three (66%) of 111 Ontario radiologists participated in the radiology webinar and evaluated the synoptic MRI report. RESULTS: A total of 78% and 90% radiologists expressed that the synoptic MRI report was easy to use and included all of the appropriate items; 82% noted that the synoptic MRI report improved the overall quality of their information, and 83% indicated they would consider using this report in their clinical practice. An MRI report audit after implementation of the synoptic MRI report showed a 39% improvement in the completeness of MRI reports and a 37% uptake of the synoptic MRI report format across the province. LIMITATIONS: Radiologists evaluating the synoptic MRI report and participating in the radiology webinar may not be representative of gastroenterologic radiologists in other geographic jurisdictions. The evaluation of completeness and uptake of the synoptic MRI reports is limited because of unmeasured differences that may occur before and after the MRI. CONCLUSIONS: A synoptic MRI report for preoperative staging of rectal cancer was successfully developed and pilot tested in the province of Ontario, Canada.