Ramzi M. Helewa

Geographical disparities of rectal cancer local recurrence and outcomes: a population-based analysis.

BACKGROUND: Challenges exist in providing high-quality cancer treatments to populations spread over large geographical areas. Local recurrence of rectal cancer is a complicated clinical problem associated with high morbidity and mortality. OBJECTIVES: The objectives of this study were to evaluate population-based rates and predictors of local recurrence of rectal cancer in the Province of Manitoba, Canada, with emphasis on the effects of geography. DESIGN: This was a population-based retrospective analysis. Administrative data from the Manitoba Cancer Registry and individual patient charts were reviewed. SETTINGS: Patients with stages I to III rectal cancer who underwent surgery with curative intent in Manitoba between 2004 and 2006 were included. MAIN OUTCOME MEASURES: The primary outcome was the development of local recurrence after surgical resection. RESULTS: Three hundred seventy patients with a mean age of 67 years were identified. The 5-year local recurrence rate was 17.4%. In multivariate analysis, relative to Winnipeg residents, rural residents, regardless of where they underwent surgery, had an increased risk of local recurrence (HR, 3.47; 95% CI, 1.74–6.92 for surgery in Winnipeg; HR, 2.98; 95% CI, 1.59–5.57 for surgery in rural Manitoba). The absence of both neoadjuvant radiotherapy and adjuvant chemotherapy was associated with a higher risk of local recurrence. Higher risk of mortality was noted for rural patients (HR, 1.90; 95% CI, 1.24–2.89) and for those who developed local recurrence (HR, 2.01; 95% CI, 1.27–3.19). CONCLUSION: Local recurrence rates for rectal cancer are high in Manitoba. Geography is an important variable, because rural status is associated with higher local recurrence rates and decreased survival. The use of neoadjuvant radiotherapy was an important predictor of lower local recurrence rates. Further initiatives are imperative to identify why rural patients experience differences in outcomes in Manitoba.

Evaluation of a Regional Acute Care Surgery Service by Residents in General Surgery

BACKGROUND Acute care surgery (ACS) services dedicated to care of acute general surgery patients have been established in many tertiary centers across Canada. Little is known about the impact of this trend on postgraduate education. In this study we aimed to evaluate ACS through a cross-sectional survey of general surgery residents in Winnipeg, Manitoba. METHODS General surgery residents at the University of Manitoba were asked to complete an anonymous survey. Basic demographic data were obtained. The educational value of ACS was assessed using 10 statements derived from the CanMEDS framework for training physicians. Resident burnout was measured using the Maslach Burnout Inventory, on emotional exhaustion, depersonalization, and personal accomplishment. RESULTS The response rate was 70% (14/20). ACS was evaluated positively based on the CanMEDS roles by the following proportions of responders: surgical skills (79%), clinical knowledge (100%), communicator (100%), collaborator (100%), manager (86%), health advocate (100%), scholar (64%), and professional (93%). Fifty percent of responders had a high score on emotional exhaustion, 43% on depersonalization, and 0% on low sense of personal accomplishment. The overall burnout was 64%. CONCLUSIONS ACS provides a comprehensive clinical experience based on the CanMEDS competencies. Despite an increased sense of personal accomplishment, residents experienced a high incidence of burnout, as demonstrated by high scores on emotional exhaustion and depersonalization of patients.

Does geography influence the treatment and outcomes of colorectal cancer? A population-based analysis.

BackgroundThe Canadian province of Manitoba covers a large geographical area but only has one major urban center, Winnipeg. We sought to determine if regional differences existed in the quality of colorectal cancer care in a publicly funded health care system.MethodsThis was a population-based historical cohort analysis of the treatment and outcomes of Manitobans diagnosed with colorectal cancer between 2004 and 2006. Administrative databases were utilized to assess quality of care using published quality indicators.ResultsA total of 2,086 patients were diagnosed with stage I to IV colorectal cancer and 42.2% lived outside of Winnipeg. Patients from North Manitoba had a lower odds of undergoing major surgery after controlling for other confounders (odds ratio (OR): 0.48, 95% confidence interval (CI): 0.26 to 0.90). No geographic differences existed in the quality measures of 30-day operative mortality, consultations with oncologists, surveillance colonoscopy, and 5-year survival. However, there was a trend towards lower survival in North Manitoba.ConclusionWe found minimal differences by geography. However, overall compliance with quality measures is low and there are concerning trends in North Manitoba. This study is one of the few to evaluate population-based benchmarks for colorectal cancer therapy in Canada.

The implementation of a transanal endoscopic microsurgery programme: initial experience with surgical performance.

Despite transanal endoscopic microsurgery (TEM) being used for over 30 years, there has been slow adoption of this modality in many centres. There remains a paucity of research regarding the learning curve and early performance of surgeons who begin to offer TEM. We sought to determine predictors of longer rates of tumour excision and improvements in operative time in a newly established TEM programme.

Surgery for Locally Advanced T4 Rectal Cancer: Strategies and Techniques.

Locally advanced T4 rectal cancer represents a complex clinical condition that requires a well thought-out treatment plan and expertise from multiple specialists. Paramount in the management of patients with locally advanced rectal cancer are accurate preoperative staging, appropriate application of neoadjuvant and adjuvant treatments, and, above all, the provision of high-quality, complete surgical resection in potentially curable cases. Despite the advanced nature of this disease, extended and multivisceral resections with clear margins have been shown to result in good oncological outcomes and offer patients a real chance of cure. In this article, we describe the assessment, classification, and multimodality treatment of primary locally advanced T4 rectal cancer, with a focus on surgical planning, approaches, and outcomes.

Longer waiting times for patients undergoing colorectal cancer surgery are not associated with decreased survival.

Wait times are a growing concern in Canadas publicly‐funded healthcare system. We sought to determine if increased wait times for colorectal cancer (CRC) treatments resulted in worse outcomes.

Perspectives From Patients and Care Providers on the Management of Fecal Incontinence: A Needs Assessment.

BACKGROUND: A large proportion of Canadians experience fecal incontinence, with no avenue for effective treatments. The Ottawa Hospital has recently started a percutaneous tibial nerve stimulation program for patients who have not improved with conservative efforts. OBJECTIVE: As part of this program implementation, a qualitative needs assessment was undertaken to better define successful outcomes and to identify barriers for program sustainability. DESIGN: This was a cross-sectional, qualitative study involving standardized, semistructured interviews. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients experiencing fecal incontinence, as well as nurses, physical therapists, and physicians, were enrolled in the study. MAIN OUTCOME MEASURES: Interview questions revolved around success definitions, barriers, and promoters of fecal incontinence care. Transcripts were analyzed to develop themes surrounding fecal incontinence care. RESULTS: Twelve interviews were undertaken raising a total of 17 different themes. Barriers to fecal incontinence care included education for both the care provider and patients. Access issues for treatments were also highlighted. Promoters of fecal incontinence care were reflected by the impact that it has on quality of life, personal hygiene, psychological burden, and activity and productivity. The definition of fecal incontinence success was focused on improvements in quality of life rather than a numerical reduction of incontinence episodes. LIMITATIONS: This study was limited in its small number of interviews conducted. We were unable to identify patients who were unable to seek out care for fecal incontinence. CONCLUSIONS: Patient and care provider education surrounding fecal incontinence is lacking. Furthermore, access for effective treatments is a real barrier for Canadians experiencing fecal incontinence. Programs should focus on improvement of overall quality of life rather than a reduction of incontinence episodes.

Rectal Cancer in 2018: A Primer for the Gastroenterologist

&NA; The rectum has distinctive anatomic and physiologic features, which increase the risk of local spread and recurrence among rectal cancers as compared to colon cancers. Essential to the management of rectal cancers is accurate endoscopic localization as well as preoperative imaging assessment of local and distant disease. Successful oncologic care is multidisciplinary including input from Gastroenterologists, Surgeons, Medical and Radiation Oncologists, Radiologists, and Pathologists. Extensive planning of curative intent is mandatory as failures of upfront treatment present great long‐term difficulty for patients and caregivers. Local recurrences are frequently associated with major morbidity including bowel and urinary obstruction, severe pain, and significantly diminished quality of life. Distant recurrence is associated with lower survival. Over the last two decades, there have been many advances in diagnostic imaging techniques as well as surgical techniques including transanal endoscopic microsurgery for very early stage cancers. Progress in curative management paradigms includes shorter courses of preoperative radiotherapy and chemotherapy doublet paradigms for perioperative treatment. This review describes the diagnosis, workup, and multimodality curative intent treatment of rectal cancers. It is emphasized that success begins in the hands and eyes of the gastroenterologist.