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Background: Despite evidence that mechanical bowel preparation (MBP) does not reduce the rate of postoperative complications, many surgeons still use MBP before surgery. We sought to appraise and synthesize the available evidence regarding preoperative bowel preparation in patients undergoing elective colorectal surgery.Methods: We searched MEDLINE, EMBASE and Cochrane Databases to identify randomized controlled trials (RCTs) comparing patients who received a bowel preparation with those who did not. Two authors reviewed the abstracts to identify articles for critical appraisal. We used the methods of the United States Preventive Services Task Force to grade study quality and level of evidence, as well as formulate the final recommendations. Outcomes assessed included postoperative infectious complications, such as anastomotic dehiscence and superficial surgical site infections.Results: Our review identified 14 RCTs and 8 meta-analyses. Based on the quality and content of these original manuscripts, we formulated 6 recommendations for various aspects of bowel preparation in patients undergoing elective colorectal surgery.Conclusion: Taking into account the lack of difference in postoperative infectious complication rates when MBP is omitted and the adverse effects of MBP, we believe that, based on the literature, MBP before surgery should be omitted. [ABSTRACT FROM AUTHOR]

Background: Following surgery for rectal cancer, two unfortunate outcomes for patients are permanent colostomy and local recurrence of cancer. We tested whether a quality-improvement strategy to change surgical practice would improve these outcomes.Methods: Sixteen hospitals were cluster-randomized to the intervention (Quality Initiative in Rectal Cancer strategy) or control (normal practice) arm. Consecutive patients with primary rectal cancer were accrued from May 2002 to December 2004. Surgeons at hospitals in the intervention arm could voluntarily participate by attending workshops, using opinion leaders, inviting a study team surgeon to demonstrate optimal techniques of total mesorectal excision, completing postoperative questionnaires, and receiving audits and feedback. Main outcome measures were hospital rates of permanent colostomy and local recurrence of cancer.Results: A total of 56 surgeons (n = 558 patients) participated in the intervention arm and 49 surgeons (n = 457 patients) in the control arm. The median follow-up of patients was 3.6 years. In the intervention arm, 70% of surgeons participated in workshops, 70% in intraoperative demonstrations and 71% in postoperative questionnaires. Surgeons who had an intraoperative demonstration provided care to 86% of the patients in the intervention arm. The rates of permanent colostomy were 39% in the intervention arm and 41% in the control arm (odds ratio [OR] 0.97, 95% confidence interval [CI] 0.63-1.48). The rates of local recurrence were 7% in the intervention arm and 6% in the control arm (OR 1.06, 95% CI 0.68-1.64).Interpretation: Despite good participation by surgeons, the resource-intense quality-improvement strategy did not reduce hospital rates of permanent colostomy or local recurrence compared with usual practice. [ABSTRACT FROM AUTHOR]

Background: We sought to assess the feasibility of applying Cancer Care Ontario's quality of care indicators to a single institution's colorectal cancer (CRC) database. We also sought to assess their utility in identifying areas that require improvement.Methods: We included patients who had surgery for CRC between 1997 and 2006 at Mount Sinai Hospital, Toronto, Ont. We excluded patients who had transanal excisions, carcinoma in situ or recurrences that required pelvic exenteration, as well as those whose information was incomplete. We obtained data from a prospective database and verified the data with hospital and office charts. We evaluated trends over a 10-year period using the Cochran-Armitage trend test.Results: During the study period there were 1005 surgical procedures performed in 987 patients with a mean age of 65.6 (standard deviation 15) years; the male:female ratio was 1:2. The most frequent tumour sites were the rectum and sigmoid colon (68%). Over the 10-year period, 9 indicators improved, including the proportion of patients with CRC identified by screening (p < 0.001), the proportion of patients who received preoperative liver imaging (p = 0.05), the proportion of rectal cancer patients who received preoperative pelvic imaging (p = 0.04), the proportion of patients with stage II or III rectal cancer who received radiotherapy (p = 0.03), the proportion of surgical specimens with more than 12 lymph nodes (p < 0.001), the proportion of pathology reports that included quantitative distal (p = 0.004) and radial (p < 0.001) margin measurements, the proportion of patients with an anastomotic leak (p = 0.03), the proportion of patients who received a colonoscopy 1 year after surgery (p < 0.001) and the proportion of operative reports that were complete (p < 0.001).Conclusion: The use of quality of care indicators to assess the quality of colorectal surgery is feasible. This study provides benchmarks that can be used to assess changes in the quality of CRC care at our institution. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the reliability and validity of the Body Image After Breast Cancer Questionnaire (BIBCQ) in a series of outpatients with breast cancer. One hundred sixty-four breast cancer patients attending outpatient clinics completed questionnaires at baseline. The patients' BIBCQ scores were compared with their scores on related psychological measures including depression, self-esteem, quality of life, and sexual functioning. Scores on the BIBCQ for women after mastectomy and breast conservation were compared. Select items of the BIBCQ were compared between women with and without breast cancer. Patients received a second questionnaire after a 2 week interval to assess test-retest reliability. Good reliability was found for the six scales (ranging from 0.77 to 0.87). The BIBCQ correlated with similar measures as predicted, but not with a measure of social desirability. The BIBCQ distinguished between women treated with lumpectomy and mastectomy, and between women with breast cancer and a control group, supporting the validity of the BIBCQ. The BIBCQ provides a reliable and valid assessment of the long-term impact of breast cancer on body image. It is suitable for use in research focusing on this issue. [ABSTRACT FROM AUTHOR]

INTRODUCTION: To describe the epidemiology of acute appendicitis in the Province of Ontario, we carried out a retrospective population-based cohort study of all patients with acute appendicitis. METHODS: Using hospital discharge abstracts of patients with acute appendicitis from all acute care hospitals in Ontario for the fiscal years 1991-1998 coded for the Canadian Institute for Health Information, we studied the demographic features, particularly age and sex, length of hospital stay (LOS), incidence, and seasonal variation of acute appendicitis. RESULTS: During the observation period, 65,675 cases of acute appendicitis occurred in Ontario. Of these, 58% of the patients were male and 35.5% had perforation. The mean (and standard deviation [SD]) LOS for patients with perforation was 6.2 (5.3) days versus 3 (1.8) days for patients with no perforation (p < 0.001). The age-specific incidence of acute appendicitis followed a similar pattern for males and females, but males had higher rates in all age groups. The incidence was highest in those aged 10-19 years. The annual age and sex-adjusted incidence of acute appendicitis was 75 per 100,000 population. The female:male age-adjusted rate ratio was 1:1.4. During the study period, the rate of acute appendicitis decreased by 5.1%, but the rate of appendicitis with perforation increased by 13%. A significant seasonal effect was also observed, with the rate of acute appendicitis being higher in the summer months. CONCLUSIONS: Appendicitis is more common in males, in those aged 10-19 years, and during the summer months. The frequency of acute appendicitis appears to be decreasing whereas the proportion of cases with perforation appears to be increasing. This may reflect a change in the population structure in Ontario and restrictions placed on the patient access to the health care system. [ABSTRACT FROM AUTHOR]

Question: Does the addition of preoperative radiotherapy increase the benefit of total mesorectal excision for rectal cancer? Design: A randomized controlled trial. Setting: A multicentre setting, which included hospitals from The Netherlands, Sweden, Canada and other European locations. Patients: The study included 1861 patients who had histologically confirmed adenocarcinoma of the rectum without evidence of distant metastases and in whom the inferior margin of the tumour was located not farther that 15 cm from the anal verge and below the level of Sl-2. Intervention: Patients were randomly assigned to treatment with preoperative radiation (5 Gy on each of 5 d) followed by total mesorectal excision (n = 897) or to total mesorectal excision alone (n = 908). Main outcome measures: Two main outcomes were measured: overall survival rate and local recurrence. Results: The table shows the results at the 2-year follow-up. Conclusion: Preoperative radiotherapy (short course) with total mesorectal excision significantly decreases the local recurrence rate compared with surgery alone at a median follow-up of 2 years. [ABSTRACT FROM AUTHOR]

Implications for the academic and interpersonal development of children and adolescents underpin a global political consensus to maintain in-classroom teaching during the ongoing COVID-19 pandemic. In support of this aim, the WHO and UNICEF have called for schools around the globe to be made safer from the risk of COVID-19 transmission. Detailed guidance is needed on how this goal can be successfully implemented in a wide variety of educational settings in order to effectively mitigate impacts on the health of students, staff, their families, and society. This review provides a comprehensive synthesis of current scientific evidence and emerging standards in relation to the use of layered prevention strategies (involving masks, distancing, and ventilation), setting out the basis for their implementation in the school environment. In the presence of increasingly infectious SARS-Cov-2 variants, in-classroom teaching can only be safely maintained through a layered strategy combining multiple protective measures. The precise measures that are needed at any point in time depend upon a number of dynamic factors, including the specific threat-level posed by the circulating variant, the level of community infection, and the political acceptability of the resultant risk. By consistently implementing appropriate prophylaxis measures, evidence shows that the risk of infection from in-classroom teaching can be dramatically reduced. Current studies indicate that wearing high-quality masks and regular testing are amongst the most important measures in preventing infection transmission; whilst effective natural and mechanical ventilation systems have been shown to reduce infection risks in classrooms by over 80%., (© 2022 The Authors. Indoor Air published by John Wiley & Sons Ltd.)

Competing Interests: The authors report no conflicts of interest.

Background: Patient engagement is the establishment of active partnerships between patients, families, and health professionals to improve healthcare delivery. The objective of this project was to conduct a series of patient engagement workshops to identify areas to improve the surgical experience and develop strategies to address areas identified as high priority., Methods: Faculty surgeons and patients were invited to participate in three in-person meetings. Evaluation included identifying and developing strategies for three priority areas to improve the surgical experience and level of engagement achieved at each meeting., Results: Sixteen faculty surgeons and 32 patients participated. Some 63 themes to improve the surgical experience were identified; the three highest-priority themes were physician communication, discharge process, and expectations at home after discharge. Individual improvement strategies for these three prioritized themes (12, 36 and 6 respectively) were used to develop a formal strategic plan, and included a physician communication survey, discharge process worksheet and video, and guideline regarding what to expect at home after discharge. Overall, the level of engagement achieved was considered high by over 85 per cent of the participants., Conclusion: A high level of patient engagement was achieved. Priorities were identified with patients and surgeons to improve surgical experience, and strategies were developed to address these areas., (© The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

This Consensus Statement provides recommendations on the prescription of pain medication at discharge from hospital for opioid-naïve adult patients who undergo elective surgery. It encourages health care providers (surgeons, anesthesiologists, nurses/nurse practitioners, pain teams, pharmacists, allied health professionals, and trainees) to (1) use nonopioid therapies and reduce the prescription of opioids so that fewer opioid pills are available for diversion and (2) educate patients and their families/caregivers about pain management options after surgery to optimize quality of care for postoperative pain. These recommendations apply to opioid-naïve adult patients who undergo elective surgery. This consensus statement is intended for use by health care providers involved in the management and care of surgical patients. A modified Delphi process was used to reach consensus on the recommendations. First, the authors conducted a scoping review of the literature to determine current best practices and existing guidelines. From the available literature and expertise of the authors, a draft list of recommendations was created. Second, the authors asked key stakeholders to review and provide feedback on several drafts of the document and attend an in-person consensus meeting. The modified Delphi stakeholder group included surgeons, anesthesiologists, residents, fellows, nurses, pharmacists, and patients. After multiple iterations, the document was deemed complete. The recommendations are not graded because they are mostly based on consensus rather than evidence., Competing Interests: No potential conflict of interest was reported by the authors., (© 2020 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Summary: The Canadian Association of General Surgeons (CAGS) Board of Directors hosted a symposium to develop a Canadian strategy for surgical quality and safety at its mid-term meeting on Feb. 24, 2018. The following 6 principles outline the consensus of this symposium, which included diverse stakeholders and surgeon leaders across Canada: 1) a Canadian quality-improvement strategy for surgery is needed; 2) quality improvement requires continuous, active and intentional effort; 3) outcome measurement alone will not drive improvement; 4) increased focus on standardization and process improvement is necessary; 5) new, large electronic medical record systems pose challenges as well as benefits in Canadian hospitals; and 6) surgeons in remote and rural hospitals must be engaged using tailored approaches., Competing Interests: A. Wei is a consultant with Ethicon, Ipsen, Shire and Celgene as well as a noncommercial consultant with Cancer Care Ontario. She declares honoraria from Shire and Celgene and travel assistance from Bayer. No other authors declare competing interests., (© 2019 Joule Inc. or its licensors)

Numerous reports have documented the effectiveness of Enhanced Recovery after Surgery (ERAS) pathways in improving recovery and decreasing morbidity and length of stay. However, there is also increasing evidence that ERAS ® guidelines are difficult to adopt and require the commitment of all members of the perioperative team. Multiple barriers related to limited hospital resources (financial, staffing, space restrictions, and education), active or passive resistance from members of the perioperative team, and lack of data and/or education have been identified. Thus, ERAS ® guidelines require a tailored implementation strategy to increase adherence., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Over the past 2 decades, there has been an increase in opioid use and subsequently, opioid deaths. The amount of opioid prescribed to surgical patients has also increased. The aim of this systematic review was to determine postdischarge opioid consumption in surgical patients compared with the amount of opioid prescribed. Secondary outcomes included adequacy of pain control and disposal methods for unused opioids., Objective: The objective of this study is to characterize postdischarge opioid consumption and prescription patterns in surgical patients., Methods: A systematic search in MEDLINE and EMBASE identified 11 patient survey studies reporting on postdischarge opioid use in 3525 surgical patients., Results: The studies reported on a variety of surgical operations, including abdominal surgery, orthopedic procedures, tooth extraction, and dermatologic procedures. The majority of patients consumed 15 pills or less postdischarge. The proportion of used opioids ranged from 5.6% to 59.1%, with an outlier of 90.1% in pediatric spinal fusion patients. Measured pain scores of those taking opioids ranged between 2 and 5 out of 10 and the majority of patients were satisfied with their pain control. Seventy percent of patients kept the excess opioids. Where planned disposal methods were reported, between 4% and 59% of patients planned proper disposal., Conclusion: This study suggests that surgical patients are using substantially less opioid than prescribed. There is a lack of awareness regarding proper disposal of leftover medication, leaving excess opioid that may be used inappropriately by the patient or others. Education for providers and clinical practice guidelines that provide guidance on prescription of outpatient of opioids are required.

Background: Enhanced recovery after surgery (ERAS) programs incorporate evidence-based practices to minimize perioperative stress, gut dysfunction, and promote early recovery. However, it is unknown which components have the greatest impact., Objective: This study aims to determine which components of ERAS programs have the largest impact on recovery for patients undergoing colorectal surgery., Methods: An iERAS program was implemented in 15 academic hospitals. Data were collected prospectively. Patients were considered compliant if >75% of the preoperative, intraoperative, and postoperative predefined interventions were adhered to. Optimal recovery was defined as discharge within 5 days of surgery with no major complications, no readmission to hospital, and no mortality. Multivariable analysis was used to model the impact of compliance and technique on optimal recovery., Results: Overall, 2876 patients were enrolled. Colon resections were performed in 64.7% of patients and 52.9% had a laparoscopic procedure. Only 20.1% of patients were compliant with all phases of the pathway. The poorest compliance rate was for postoperative interventions (40.3%) which was independently associated with an increase in optimal recovery (RR = 2.12, 95% CI 1.81-2.47). Compliance with ERAS interventions remained associated with improved outcomes whether surgery was performed laparoscopically (RR = 1.55, 95% CI 1.23-1.96) or open (RR = 2.29, 95% CI 1.68-3.13). However, the impact of ERAS compliance was significantly greater in the open group (P < 0.001)., Conclusions: Postoperative compliance is the most difficult to achieve but is most strongly associated with optimal recovery. Although our data support that ERAS has more effect in patients undergoing open surgery, it also showed a significant impact on patients treated with a laparoscopic approach.

Objective: There have been remarkable advances over the past decade in neural prostheses to restore lost motor function. However, restoration of somatosensory feedback, which is essential for fine motor control and user acceptance, has lagged behind. With an increasing interest in using electrical stimulation to restore somatosensory sensations within the peripheral (PNS) and central nervous systems (CNS), it is critical to characterize the percepts evoked by electrical stimulation in a standardized manner with a validated psychometric questionnaire. This will allow comparison of results from applications at various nervous system levels in multiple settings., Approach: We compiled a summary of published reports of somatosensory percepts that were elicited by electrical stimulation in humans and used these to develop a new psychometric questionnaire., Results: This new questionnaire was able to characterize subjective evoked sensations with good test-retest reliability (Spearman's correlation coefficients ranging 0.716  ⩽  ρ  ⩽  1.000, p  ⩽  0.005) in 13 subjects receiving stimulation through neural implants in both the CNS and PNS. Furthermore, the new questionnaire captured more descriptors (M  =  2.65, SD  =  0.91) that would have been missed by being categorized as 'other sensations', using a previous questionnaire (M  =  1.40, SD  =  0.77, t(12)  =  -10.24, p  <  0.001). Lastly, the new questionnaire was able to capture different descriptors within subjects using different patterns of electrical stimulation (Wilk's Lambda  =  0.42, F(3, 10)  =  4.58, p  =  0.029)., Significance: This new somatosensory psychometric questionnaire will aid in establishing consistency and standardization of reporting in future studies of somatosensory neural prostheses.

Background: Enhanced Recovery After Surgery (ERAS) guidelines have been widely promoted and supported largely due to several studies showing decreased post-operative complications and length of stay. The objective of this study was to review the emergency room (ER) visits and readmission rates and reasons for both in patients who were part of the Implementation of an Enhanced Recovery After Surgery (iERAS) program for colorectal surgery., Methods: All patients having elective colorectal surgery at 15 academic hospitals were enrolled in the iERAS program. All patients were prospectively followed until 30 days post-discharge. Data were analyzed using descriptive statistics and multivariable analysis., Results: A total of 2876 patients (48% female; mean 60 years old) were enrolled. Cancer was the most frequent indication (68.2%) for surgery. Overall, the median length of stay (LOS) was 5 days. Post-discharge, 359 (11.6%) of patients had a visit to the ER not requiring admission. The most common reasons for visiting the ER were surgical site infections (SSI) (34.5%), other wound complications (10.0%), and urinary tract infections (UTI) (8.6%). In addition, a smaller proportion of patients, 260 (8.2%) required readmission. The most common reasons for readmission were ileus and nausea/vomiting (26.1%), intra-abdominal abscess (23.9%), and SSI (11.5%). Patient and disease factors associated with ER visits, on multivariable analysis, included extremes of BMI (RR 1.02, 95%CI 1.01-1.04, p = 0.002), rectal surgery versus colon surgery (RR 1.34, 95%CI 1.14-1.58, p < 0.001), and open operative approach (RR 1.63, 95%CI 1.28-2.09, p < 0.001). Independent factors associated with hospital readmissions included rectal surgery (RR 1.89, 95%CI 1.34-2.77, p < 0.001), formation of a stoma (RR 1.34, 95%CI 1.04-1.74, p = 0.026), and reoperation during first admission (RR 4.60, 95%CI 3.50-6.05, p < 0.001). Length of stay of 5 days or less was not associated with ER visits or readmission (RR 0.99, 95%CI 0.72-1.35 and RR 0.91, 95%CI 0.71-1.18, respectively)., Conclusion: Following colorectal surgery using an ERAS pathway, shortened length of stay is not associated with an increased return to the ER or hospital readmission. The majority of return visits to the hospital are ER visits not requiring readmission and the predominant reason for return are surgical site infections and wound complications.

Context: The increasing prevalence of obesity and diabetes greatly influences the risk for cardiovascular (CV) comorbidities and affects the quality of life of many people. However, the relationship among diabetes, obesity, and cardiovascular risk is complex and requires further investigation to understand the biological milieu connecting these conditions., Objective: The aim of the current study was to explore the relationship between biological markers of adipose tissue function (adiponectin) and CV risk (apolipoprotein B) in body mass index (BMI)-matched participants with and without diabetes., Design: Nested case-control study., Setting: The Atlantic Partnership for Tomorrow's Health (PATH) cohort represents four Atlantic Canadian provinces: Newfoundland and Labrador, New Brunswick; Nova Scotia; and Prince Edward Island., Participants: The study population (n = 480) was aged 35 to 69 years, 240 with diabetes and 240 without diabetes., Main Outcome Measures: Groups with and without diabetes were matched for sex and BMI. Both measured and self-reported data were used to examine disease status, adiposity, and lifestyle factors. Immunoassays were used to measure plasma markers., Results: In these participants, plasma adiponectin levels were lower among those with diabetes than those without diabetes; these results were sex-specific, with a strong relationship seen in women. In contrast, in participants matched for sex and adiposity, plasma apoB levels were similar between participants with and those without diabetes., Conclusion: Measures of adiposity were higher in participants with diabetes. However, when matched for adiposity, the adipokine adiponectin exhibited a strong inverse association with diabetes., Competing Interests: Disclosure Summary: The authors have nothing to disclose.

Background: With the adoption of enhanced recovery after surgery (ERAS) programs, patients are being discharged earlier and require more post-discharge teaching, educational materials, and information., Objective: The purpose of this study is to assess satisfaction, discharge needs, and follow-up concerns of patients within an ERAS implementation program (iERAS)., Methods: Between 2012 and 2015, the iERAS program was undertaken at an academic hospital where 554 patients having elective colorectal surgery were enrolled. After discharge, patients were sent a survey containing multiple choice questions, preference ranking, and open-ended questions. Free-text responses were analyzed through a thematic approach., Results: Overall, 496 patients were mailed surveys and 219 (44.2%) completed the survey. Ninety-three percent were satisfied with the discharge information, and 90% felt they were ready for discharge. Eighty-six percent of patients saw their surgeon at 6 weeks, and 88% were satisfied with this follow-up plan. Some patients felt they had inadequate post-operative information, including how to resolve complications while at home and lack of reliable information for common post-operative occurrences. Patients with ostomies wanted more information about what to expect post-discharge and what symptoms were normal. Support from the homecare team and having a surgical nurse available were considered to be essential., Conclusions: Improved post-operative education for surgical patients prior to discharge within iERAS is required to facilitate patient-centered discharge planning. Such interventions may help decrease unplanned hospital visits during the immediate post-discharge period.

Objective: The objective of the study was to determine whether compliance with Enhanced Recovery after Surgery (ERAS) urinary catheter recommendations is associated with decreased urinary tract infections (UTI) and length of stay (LOS)., Methods: Patients having colorectal surgery at 15 academic hospitals were included. Patient and outcome data were collected prospectively. The guideline recommends that urinary catheters following colonic and rectal procedures should be removed at or before 24 and 72 h, respectively., Results: Two thousand nine hundred and twenty-seven patients (1397 females and 1522 males; mean age 60.3 years) were enrolled. Small bowel or colonic procedures were performed in 1897 (64.9%) and rectal procedures in 1030 (35.2%) patients. Overall, 53.2% of patients had their catheter removed in compliance with the guidelines (44.3% after colonic resections and 69.5% after rectal resections). Following colonic operations, 0.8% of patients who were guideline compliant had a UTI compared to 4.1% non-compliant patients (RR 0.20, 95% CI 0.07-0.58; p = 0.003). Following rectal operations, 3.5% of patients who were guideline compliant had a UTI compared to 9.6% of patients who were non-compliant (RR 0.37, 95% CI 0.20-0.68; p = 0.001). Median LOS was decreased in compliant patients: 4 vs 5 days following colonic procedures (RR 0.73, 95% CI 0.66-0.82; p < 0.0001) and 5 vs 8 days following rectal procedures (RR 0.54, 95% CI 0.49-0.59; p < 0.001)., Conclusion: Early removal of urinary catheters is associated with a decreased risk of UTI and LOS.

Background: We aimed to summarize the outcomes of ulcerative colitis (UC) patients receiving an ileal pouch-anal anastamosis (IPAA) over an 11-year period at a high-volume Canadian inflammatory bowel disease (IBD) center., Methods: A retrospective chart review was performed for subjects with UC who underwent IPAA between 2002 and 2013. Patient charts were reviewed for demographic data, clinical characteristics, preoperative medical treatment, and surgical outcomes. Univariate and multivariate logistic regression modeling were used to determine significant factors in postoperative outcomes., Results: Seven hundred fifty-eight were included from the IBD database. The median age at the time of surgery was 37.1 (±12.1). Mean preoperative disease duration was 8.1 years (±8.7). Three hundred sixty-nine patients (48.7 %) had systemic corticosteroids (>15 mg/day) within 30 days prior to surgery. Of these, 286 patients had high dose (>30 mg/day) corticosteroids within 7 days of their first surgery. One hundred nine (14.0 %) IPAA procedures were performed laparoscopically. Pelvic pouches were created in traditional 2 (n = 460) and 3 (n = 285) stages; the remainder (n = 13) was performed in non-traditional staged operations. Early complications, defined as occurring within the same stay in hospital, consisted of pelvic abscess (n = 135, 17.8 %), small bowel obstruction (n = 134, 17.7 %), wound infection (n = 108, 14.3 %), and deep vein thrombosis (n = 33, 4.4 %). The overall pouch leak rate was 92 (12.1 %). There was one death in our study. The median length of stay was 10.3 days (SD6.0). Late complications, defined as occurring after discharge from hospital, consisted of anal stricture (n = 55, 7.3 %), pouch fistula (n = 26, 3.4 %), and functional pouch failure (n = 7, 0.9 %)., Conclusions: IPAA has been found to be a safe and effective method of surgical management of UC patients in a high-volume IBD center.

Background: There are conflicting data regarding the effect of previous exposure to anti-tumor necrosis factor (anti-TNF) therapy on complication rates after pelvic pouch surgery for patients with ulcerative colitis (UC). In particular, there is concern surrounding the rates of pouch leaks and infectious complications, including pelvic abscesses, in anti-TNF-treated subjects who require ileal pouch-anal anastomosis (IPAA) surgery., Methods: A retrospective study was performed in UC subjects who underwent IPAA between 2002 and 2013. Demographic data, clinical data, use of anti-TNF therapy, steroids, immunosuppressants, and surgical outcomes were assessed., Results: Seven hundred seventy-three patients with UC/IPAA were reviewed. Fifteen patients were excluded from the analysis because of missing data. There were 196 patients who were exposed to anti-TNF therapy and 562 patients who were not exposed to anti-TNF therapy preoperatively. There were no significant differences in the postoperative IPAA leak rate between those exposed to anti-TNF therapy and the control group (n = 26 [13.2%] versus 66 [11.7%], respectively, P = 0.44). In addition, there were no significant differences in the postoperative 2-stage IPAA leak rate in those who had been operated on within 15 days from the last anti-TNF dose (n = 10), within 15 to 30 days (n = 17), or 31 to 180 days (n = 54) (10%, 5.9%, and 14.8% respectively, P = 0.43) nor were there differences based on the presence of detectable infliximab serum levels., Conclusions: Preoperative anti-TNF therapy in patients with UC is not associated with an increased risk of infectious and noninfectious complications after IPAA including pelvic abscesses, leaks, and wound infections.

Background and Aims: There is a paucity of evidence in ulcerative colitis [UC] comparing the traditional two-stage [total proctocolectomy with ileal pouch-anal anastomosis [IPAA] and diverting ileostomy, followed by ileostomy closure] vs the modified two-stage restorative proctocolectomy [subtotal colectomy with end ileostomy, followed by completion proctectomy and IPAA, without diverting ileostomy]. This study examines the risk of anastomotic leak following IPAA in traditional vs modified two-stage IPAA for UC patients., Methods: This was a single-institution, retrospective study of all UC patients who underwent a traditional or modified two-stage IPAA between 2002 and 2013. The primary outcome was anastomotic leak following IPAA., Results: In all, 460 patients had a two-stage IPAA procedure; 223 [48.5%] patients underwent traditional two-stage IPAA and 237 [51.5%] patients received the modified two-stage procedure. There was more preoperative enteral corticosteroid use [44.7% vs 33.2%, p = 0.04] before the first surgery in the modified two-stage group compared with the traditional two-stage group. The modified two-stage group had higher UC disease severity at presentation [86.9% patients with moderate/severe UC vs 73.1%, p < 0.01]. However, the modified two-stage group had a lower rate of anastomotic leak following IPAA [4.6% vs 15.7%, p < 0.01] and was associated with a lower risk of anastomotic leak on univariate (odds ratio [OR] 0.26, 95% confidence interval [CI] 0.13, 0.52] and multivariate analysis [OR 0.27, 95% CI 0.12, 0.57]., Conclusions: Patients with ulcerative colitis who received the modified two-stage IPAA had a significantly lower rate of anastomotic leak following pouch creation, compared with the traditional two-stage procedure., (Copyright © 2016 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Despite guidelines recommending restrictive red blood cell transfusion (RBCT) strategies, perioperative transfusion practices still vary significantly. To understand the underlying mechanisms that lead to gaps in practice, we sought to assess the attitudes of surgeons regarding the perioperative management of anemia and use of RBCT in patients having gastrointestinal surgery., Methods: We conducted a self-administered Web-based survey of general surgery staff and residents, in a network of eight academic institutions at the University of Toronto. We developed a questionnaire using a systematic approach of items generation and reduction. We tested face and content validity and test-retest reliability. We administered the survey via emails, with planned reminders., Results: Total response rate was 48.1 % (62/125). Half (51.0 %) of respondents stated that they were unlikely to conduct a preoperative anemia work-up. About 54.0 % reported ordering preoperative oral iron supplementation for anemia. Most respondents indicated using a 70 g/L hemoglobin trigger (92.0 %) for transfusion. Factors increasing thresholds above 70 g/L included cardiac comorbidity (58.0 %), acute cardiac disease (94.0 %), symptomatic anemia (68.0 %), and suspected bleeding (58.0 %). With those factors, the transfusion threshold often increased above 90 g/L. Respondents perceived RBCTs to increase the postoperative morbidity (62 %), but not to impact the mortality (48 %) and cancer recurrence (52 %). Institutional protocols (68.0 %), blood conservation clinics (44.0 %), and clinical practice guidelines (84.0 %) were believed to encourage restrictive use of RBCTs., Conclusion: Self-reported perioperative transfusion practices for GI surgery are heterogeneous. Few respondents investigated preoperative anemia. Stated use of RBCT indications varied from recommendations in published guidelines for patients with symptomatic anemia. Establishing team consensus and implementing local blood management guidelines appear necessary to improve uptake of evidence-based recommendations.

Background: The indications for interval elective colectomy following diverticulitis are unclear; evidence lends increasing support for nonoperative management., Objective: This study aims to evaluate the temporal trends in the use of elective colectomy following diverticulitis., Design: This is a population-based retrospective cohort study using administrative discharge data., Setting: This study was conducted in Ontario, Canada., Patients: Patients who had had an episode of diverticulitis managed nonoperatively and were eligible for elective colectomy, from 2002 to 2012, were selected., Main Outcome Measures: Changes in the proportion of patients who undergo elective colectomy following an episode of diverticulitis treated nonoperatively were evaluated. Cochran-Armitage was used to test for trends; adjusted analysis was performed by using multivariable logistic regression with generalized estimating equations., Results: A total of 14,124 patients were admitted with an episode of diverticulitis and treated nonoperatively, making them eligible for interval elective colectomy. Median follow-up was 3.9 years (maximum, 10; interquartile range, 1.7-6.4). Overall, 1342 (9.5%) patients underwent elective colectomy; 33% of these colectomies were performed laparoscopically, and 7.5% patients received an ostomy. In-hospital mortality was 0.2%. The majority (76%) of elective operations were performed within 1 year of discharge (median, 160 days; interquartile range, 88-346). The proportion of patients undergoing elective colectomy within 1 year of discharge declined from 9.6% of patients in 2002 to 3.9% by 2011 (p < 0.001). The decline was most pronounced in patients <50 years of age (from 17% to 5%), and those with complicated disease (from 28% to 8%) (all p < 0.001). In multivariable regression, younger age, lower medical comorbidity, complicated disease, and early readmission were associated with elective colectomy. After adjusting for changes in patient characteristics, the odds of elective surgery decreased by 0.93 per annum (adjusted OR; 95% CI, 0.90-0.95)., Limitations: Administrative health databases contain limited clinical detail; the rationale for elective surgery was not available., Conclusions: Consistent with evolving practice guidelines, there has been a decrease in the use of elective colectomy following an episode of diverticulitis.

Abstract: There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.

Despite existing evidence-based practice guidelines for the management of acute pancreatitis, clinical compliance with recommendations is poor. We conducted a retrospective review of 248 patients admitted between 2010 and 2012 with acute pancreatitis at eight University of Toronto affiliated hospitals. We included all patients admitted to ICU (52) and 25 ward patients from each site (196). Management was compared with the most current evidence used in the Best Practice in General Surgery Management of Acute Pancreatitis Guideline. Fifty-six patients (22.6 %) had only serum lipase tested for biochemical diagnosis. Admission ultrasound was performed in 174 (70.2 %) patients, with 69 (27.8 %) undergoing ultrasound and CT. Of non-ICU patients, 158 (80.6 %) were maintained nil per os, and only 18 (34.6 %) ICU patients received enteral nutrition, commencing an average 7.5 days post-admission. Fifty (25.5 %) non-ICU patients and 25 (48.1 %) ICU patients received prophylactic antibiotics. Only 24 patients (22.6 %) with gallstone pancreatitis underwent index admission cholecystectomy. ERCP with sphincterotomy was under-utilized among patients with biliary obstruction (16 [31 %]) and candidates for prophylactic sphincterotomy (18 [22 %]). Discrepancies exist between the most current evidence and clinical practice within the University of Toronto hospitals. A guideline, knowledge translation strategy, and assessment of barriers to clinical uptake are required to change current clinical practice.

Background: Enhanced Recovery After Surgery (ERAS) protocols have been shown to increase recovery, decrease complications, and reduce length of stay. However, they are difficult to implement., Objective: To develop and implement an ERAS clinical practice guideline (CPG) at multiple hospitals., Methods: A tailored strategy based on the Knowledge-to-action (KTA) cycle was used to develop and implement an ERAS CPG at 15 academic hospitals in Canada. This included an initial audit to identify gaps and interviews to assess barriers and enablers to implementation. Implementation included development of an ERAS guideline by a multidisciplinary group, communities of practice led by multidiscipline champions (surgeons, anesthesiologists, and nurses) both provincially and locally, educational tools, and clinical pathways as well as audit and feedback., Results: The initial audit revealed there was greater than 75% compliance in only 2 of 18 CPG recommendations. Main themes identified by stakeholders were that the CPG must be based on best evidence, there must be increased communication and collaboration among perioperative team members, and patient education is essential. ERAS and Pain Management CPGs were developed by a multidisciplinary team and have been adopted at all hospitals. Preliminary data from more than 1000 patients show that the uptake of recommended interventions varies but despite this, mean length of stay has decreased with low readmission rates and adverse events., Conclusions: On the basis of short-term findings, our results suggest that a tailored implementation strategy based on the KTA cycle can be used to successfully implement an ERAS program at multiple sites.

Background: Approximately 80% of patients with ulcerative colitis (UC) have intermittently active disease and up to 20% will require a colectomy, but little data available on predictors of poor disease course. The aim of this study was to identify clinical and genetic markers that can predict prognosis., Methods: Medical records of patients with UC with ≥5 years of follow-up and available DNA and serum were retrospectively assessed. Immunochip was used to genotype loci associated with immune mediated inflammatory disorders (IMIDs), inflammatory bowel diseases, and other single nucleotide polypmorphisms previously associated with disease severity. Serum levels of pANCA, ASCA, CBir1, and OmpC were also evaluated. Requirement for colectomy, medication, and hospitalization were used to group patients into 3 prognostic groups., Results: Six hundred one patients with UC were classified as mild (n = 78), moderate (n = 273), or severe disease (n = 250). Proximal disease location frequencies at diagnosis were 13%, 21%, and 30% for mild, moderate, and severe UC, respectively (P = 0.001). Disease severity was associated with greater proximal extension rates on follow-up (P < 0.0001) and with shorter time to extension (P = 0.03) and to prednisone initiation (P = 0.0004). When comparing severe UC with mild and moderate UC together, diagnosis age >40 and proximal disease location were associated with severe UC (odds ratios = 1.94 and 2.12, respectively). None of the single nucleotide polypmorphisms or serum markers tested was associated with severe UC, proximal disease extension or colectomy., Conclusions: Older age and proximal disease location at diagnosis, but not genetic and serum markers, were associated with a more severe course. Further work is required to identify biomarkers that will predict outcomes in UC.

Little is known about the effects of fatty acids on adiponectin oligomer assembly and trafficking. The aim of this study was to examine the effects of different fatty acids on adiponectin transport and secretion in differentiated 3T3-L1 adipocytes. Subcellular fractionation and immunofluorescence microscopy revealed that the majority of cellular adiponectin was located in the endoplasmic reticulum (ER). Adiponectin secretion was increased by treatment with fatty acids, including eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and several fatty acids changed the cellular localization of adiponectin. Adiponectin secretion has been shown to be altered by ER stress and interactions with ER chaperone proteins. However these mechanisms were not influenced by fatty acids, suggesting that alternative mechanisms must be responsible for the increased secretion of adiponectin observed with fatty acid treatment. Secretion of adiponectin was blocked by Brefeldin A, but we identified a minor pool of adiponectin that could be secreted from beyond the Brefeldin A block. Exosomes appeared to contribute to a minor amount of adiponectin secreted from the cell, and exosome release was increased by treatment with DHA. These data suggest that the ER is an important site of adiponectin accumulation and that treatment with long chain omega-3 fatty acids increases adiponectin release. Furthermore, the secretory pathway of adiponectin is complex, involving both the classical ER-Golgi pathway as well as unconventional secretory mechanisms such as an exosome-mediated pathway., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: Although several studies have reported high rates of sexual dysfunction in patients treated for rectal cancer, most studies have been limited by retrospective design, failure to use validate instruments, and a limited number of female patients., Objectives: The objectives of this study were to 1) prospectively assess changes in sexual function before and after treatment for rectal cancer and 2) identify potential areas for improved care of patients who have rectal cancer with sexual dysfunction., Design: This study is a prospective, longitudinal survey., Settings: This study was conducted at 4 tertiary care academic hospitals., Patients: The patients included had newly diagnosed rectal cancer., Main Outcome Measures: Subjects completed the European Organization for Research and Treatment Quality of Life Cancer Module and Colorectal Cancer Module, International Index of Erectile Function, and Female Sexual Function Index questionnaires before the start of treatment, after the completion of preoperative chemoradiotherapy, and 1 year after surgery., Results: Forty-five patients completed the study, and the overall results showed significant sexual dysfunction in both male and female subjects that continued to increase from baseline up to 1 year after surgery. In male subjects, sexual activity, interest, and enjoyment remained relatively stable, despite increasing sexual problems. However, for female patients, although sexual activity and interest remained relatively stable, sexual enjoyment worsened as sexual problems increased., Limitations: The study closed before reaching the target sample size owing to lower than anticipated accrual rates. Post hoc analysis included qualitative interviews with patients to explore reasons for low recruitment., Conclusions: The results of this study show that sexual problems continue to increase up to 1 year after surgery. Despite this, sexual interest in both male and female patients remained relatively unchanged suggesting that other aspects of sexuality, not just physiologic function, also need to be evaluated. Future studies to assist and educate physicians on how to initiate a discussion about sexuality and identify patients in "distress" because of sexual problems are important.

Background: Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approach to patient care that has become the standard in elective colorectal surgery. Implemented globally, ERAS programmes represent a considerable change in practice for many surgical care providers. Our current understanding of specific implementation and sustainability challenges is limited. In January 2013, we began a 2-year ERAS implementation for elective colorectal surgery in 15 academic hospitals in Ontario. The purpose of this study was to understand the process enablers and barriers that influenced the success of ERAS implementation in these centres with a view towards supporting sustainable change., Methods: A qualitative process evaluation was conducted from June to September 2014. Semi-structured interviews with implementation champions were completed, and an iterative inductive thematic analysis was conducted. Following a data-driven analysis, the Normalization Process Theory (NPT) was used as an analytic framework to understand the impact of various implementation processes. The NPT constructs were used as sensitizing concepts, reviewed against existing data categories for alignment and fit., Results: Fifty-eight participants were included: 15 surgeons, 14 anaesthesiologists, 15 nurses, and 14 project coordinators. A number of process-related implementation enablers were identified: champions' belief in the value of the programme, the fit and cohesion of champions and their teams locally and provincially, a bottom-up approach to stakeholder engagement targeting organizational relationship-building, receptivity and support of division leaders, and the normalization of ERAS as everyday practice. Technical enablers identified included effective integration with existing clinical systems and using audit and feedback to report to hospital stakeholders. There was an overall optimism that ERAS implementation would be sustained, accompanied by concern about long-term organizational support., Conclusions: Successful ERAS implementation is achieved by a complex series of cognitive and social processes which previously have not been well described. Using the Normalization Process Theory as a framework, this analysis demonstrates the importance of champion coherence, external and internal relationship building, and the strategic management of a project's organization-level visibility as important to ERAS uptake and sustainability.

Background: We previously reported that fish proteins can alleviate metabolic syndrome (MetS) in obese animals and human subjects., Objectives: We tested whether a salmon peptide fraction (SPF) could improve MetS in mice and explored potential mechanisms of action., Methods: ApoB(100) only, LDL receptor knockout male mice (LDLR(-/-)/ApoB(100/100)) were fed a high-fat and -sucrose (HFS) diet (25 g/kg sucrose). Two groups were fed 10 g/kg casein hydrolysate (HFS), and 1 group was additionally fed 4.35 g/kg fish oil (FO; HFS+FO). Two other groups were fed 10 g SPF/kg (HFS+SPF), and 1 group was additionally fed 4.35 g FO/kg (HFS+SPF+FO). A fifth (reference) group was fed a standard feed pellet diet. We assessed the impact of dietary treatments on glucose tolerance, adipose tissue inflammation, lipid homeostasis, and hepatic insulin signaling. The effects of SPF on glucose uptake, hepatic glucose production, and inducible nitric oxide synthase activity were further studied in vitro with the use of L6 myocytes, FAO hepatocytes, and J774 macrophages., Results: Mice fed HFS+SPF or HFS+SPF+FO diets had lower body weight (protein effect, P = 0.024), feed efficiency (protein effect, P = 0.018), and liver weight (protein effect, P = 0.003) as well as lower concentrations of adipose tissue cytokines and chemokines (protein effect, P ≤ 0.003) compared with HFS and HFS+FO groups. They also had greater glucose tolerance (protein effect, P < 0.001), lower activation of the mammalian target of rapamycin complex 1/S6 kinase 1/insulin receptor substrate 1 (mTORC1/S6K1/IRS1) pathway, and increased insulin signaling in liver compared with the HFS and HFS+FO groups. The HFS+FO, HFS+SPF, and HFS+SPF+FO groups had lower plasma triglycerides (protein effect, P = 0.003; lipid effect, P = 0.002) than did the HFS group. SPF increased glucose uptake and decreased HGP and iNOS activation in vitro., Conclusions: SPF reduces obesity-linked MetS features in LDLR(-/-)/ApoB(100/100) mice. The anti-inflammatory and glucoregulatory properties of SPF were confirmed in L6 myocytes, FAO hepatocytes, and J774 macrophages., (© 2015 American Society for Nutrition.)

Objective: Explore the barriers and enablers to adoption of an Enhanced Recovery after Surgery (ERAS) program by the multidisciplinary perioperative team responsible for the care of elective colorectal surgical patients., Background: ERAS programs include perioperative interventions that when used together have led to decreased length of stay while increasing patient recovery and satisfaction. Despite the known benefits of ERAS programs, uptake remains slow., Methods: Semistructured interviews were conducted with general surgeons, anesthesiologists, and ward nurses at 7 University of Toronto-affiliated hospitals to identify potential barriers and enablers to adoption of 18 ERAS interventions. Grounded theory was used to thematically analyze the transcribed interviews., Results: Nineteen general surgeons, 18 anesthesiologists, and 18 nurses participated. The mean time of each interview was 18 minutes. Lack of manpower, poor communication and collaboration, resistance to change, and patient factors were cited by most as barriers. Discipline-specific issues were identified although most related to resistance to change. Overall, interviewees were supportive of implementation of a standardized ERAS program and agreed that a standardized guideline based on best evidence; standardized order sets; and education of the staff, patients, and families are essential., Conclusions: Multidisciplinary perioperative staff supported the implementation of an ERAS program at the University of Toronto-affiliated hospitals. However, major barriers were identified, including the need for patient education, increased communication and collaboration, and better evidence for ERAS interventions. Identifying these barriers and enablers is the first step toward successfully implementing an ERAS program.

The successful transfer of evidence into clinical practice is a slow and haphazard process. We report the outcome of a 5-year knowledge translation (KT) strategy to increase adherence with a clinical practice guideline (CPG) for mechanical bowel preparation (MBP) for elective colorectal surgery patients. A locally tailored CPG recommending MBP practices was developed. Data on MBP practices were collected at six University of Toronto hospitals before CPG implementation as well as after two separate KT strategies. KT strategy #1 included development of the CPG, education by opinion leaders, reminder cards, and presentations of data. KT strategy #2 included selection of hospital champions, development of communities of practice, education, reminder cards, electronic updates, pre-printed standardized orders, and audit and feedback. A total of 744 patients (400 males, 344 females, mean age 57.0) were included. Compliance increased from 58.6 to 70.4% after KT strategy #1 and to 81.1% after KT strategy #2 (p < 0.001). Using a tailored KT strategy, increased compliance was observed with CPG recommendations over time suggesting that a longitudinal KT strategy is required to increase and sustain compliance with recommendations. Furthermore, different strategies may be required at different times (i.e., educational sessions initially and reminders and standardized orders to maintain adherence).

Purpose: Ileal pouch anal anastomosis (IPAA) is the procedure of choice in patients requiring surgery for ulcerative colitis (UC) and familial adenomatous polyposis (FAP). There are few data on reconstruction with the IPAA in patients with colorectal cancer (CRC). This study assessed the outcomes of the IPAA compared to proctocolectomy and permanent ileostomy (PI) on these patients., Methods: Between 1983 and 2013, over 2800 patients with CRC have been treated at the Mount Sinai Hospital (MSH). Demographic, surgical, pathological, and outcome data for all patients have been maintained in a database-73 patients were treated for CRC with proctocolectomy: 39 patients with IPAA and 34 patients with PI. Clinical features, pathologic findings, and survival outcomes were compared between these groups., Results: Each group was similar with respect to gender, stage, and histologic grade. Patients undergoing IPAA were significantly younger. The diagnosis leading to proctocolectomy was more commonly UC or FAP in patients treated with IPAA (39/39 vs. 23/34, p = 0.001). Rectal cancer subgroups were similar in age, sex, TNM stage, T-stage, height of tumor, and histologic grade. There was no significant difference in overall or disease free survival between groups for colon or rectal primaries. Analysis using the Cochran-Armitage trend test suggests that utilization of IPAA has increased over time (p = 0.002)., Conclusions: The IPAA is a viable and safe option to select for patients who would otherwise require PI. Increased experience and improved outcomes following IPAA has led to its more liberal use in selected patients.

Background: Comparative outcome data for laparoscopic and open subtotal colectomy in IBD are lacking and often difficult to interpret owing to low case volumes, heterogeneity in case mix, and variation in laparoscopic technique., Objective: This study aimed to determine the safety of laparoscopic subtotal colectomy in severe colitis and to determine whether the laparoscopic approach improved short-term outcomes in comparison with the open approach., Design: This was a retrospective cohort study using data from a prospectively maintained clinical database., Setting: This study was conducted at a single center, Mount Sinai Hospital, Toronto., Patients: All patients undergoing subtotal colectomy for either ulcerative or Crohn's colitis between 2000 and 2011 were included., Intervention: A standardized operative technique was used for both laparoscopic and open subtotal colectomies. Cases performed by non-laparoscopic surgeons were excluded., Main Outcome Measures: Perioperative outcome measures were operative duration, estimated blood loss, total morphine requirement, and length of postoperative stay. Postoperative outcome measures were the rates of minor and major complications., Results: Laparoscopic subtotal colectomies were performed in 131 of 290 cases (45.2%). Nine patients required conversion to an open procedure (6.9%). The uptake of laparoscopic subtotal colectomy increased from 10.2% in 2000/2001 to 71.7% in 2010/2011. Regression analysis with propensity-score adjustment for operative approach revealed that the operative duration was 25.5 minutes longer in laparoscopic cases (95% CI 12.3-38.6; p < 0.001), but that patients experienced fewer minor complications (OR 0.47; 95% CI 0.23-0.96; p = 0.04) and required less morphine (adjusted difference, -72.8 mg; 95% CI 4.9-141; p = 0.04)., Limitations: The inherent selection bias of this retrospective cohort study may not be accounted for by multivariate analysis with propensity-score adjustment., Conclusions: Laparoscopic subtotal colectomy is safe and may reduce the rate of minor postoperative complications. The increase in operative duration reflects the technical demands associated with this procedure (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A160).

Background: There is increasing evidence to support the use of percutaneous abscess drainage, laparoscopy, and primary anastomosis in managing acute diverticulitis., Objective: The aim of this study was to evaluate how practices have evolved and to determine the effects on clinical outcomes., Design: This is a population-based retrospective cohort study using administrative discharge data., Setting: This study was conducted in Ontario, Canada., Patients: All patients had been hospitalized for a first episode of acute diverticulitis (2002-2012)., Main Outcome Measures: Temporal changes in treatment strategies and outcomes were evaluated by using the Cochran-Armitage test for trends. Multivariable logistic regression with generalized estimating equations was used to test for trends while adjusting for patient characteristics., Results: There were 18,543 patients hospitalized with a first episode of diverticulitis, median age 60 years (interquartile range, 48-74). From 2002 to 2012, there was an increase in the proportion of patients admitted with complicated disease (abscess, perforation), 32% to 38%, yet a smaller proportion underwent urgent operation, 28% to 16% (all p < 0.001). The use of percutaneous drainage increased from 1.9% of admissions in 2002 to 3.3% in 2012 (p < 0.001). After adjusting for changes in patient and disease characteristics over time, the odds of urgent operation decreased by 0.87 per annum (95% CI, 0.85-0.89). In those undergoing urgent surgery (n = 3873), the use of laparoscopy increased (9% to 18%, p <0.001), whereas the use of the Hartmann procedure remained unchanged (64%). During this time, in-hospital mortality decreased (2.7% to 1.9%), as did the median length of stay (5 days, interquartile range, 3-9; to 3 days, interquartile range, 2-6; p <0.001)., Limitations: There is the potential for residual confounding, because clinical parameters available for risk adjustment were limited to fields existing within administrative data., Conclusions: There has been an increase in the use of nonoperative and minimally invasive strategies in treating patients with a first episode of acute diverticulitis. However, the Hartmann procedure remains the most frequently used urgent operative approach. Mortality and length of stay have improved during this time.

Objective: To characterize the clinical course of patients with diverticulitis after nonoperative management and determine factors associated with readmission and subsequent emergency surgery., Background: Clinical course of this disease remains poorly understood; indications for elective colectomy are unclear., Methods: This was a retrospective cohort study of patients managed nonoperatively after a first episode of diverticulitis in Ontario, Canada (2002-2012). Time-to-event analysis and Fine and Gray multivariable regression were used to characterize the risks of readmission and emergency surgery for diverticulitis, accounting for death and elective colectomy as competing events., Results: A total of 14,124 patients were followed for a median of 3.9 years (maximum 10, interquartile range: 1.7-6.4). Five-year cumulative incidence was 9.0% for readmission, 1.9% for emergency surgery, and 14.1% for all-cause mortality. Patients younger than 50 years had higher incidence of readmission than patients aged 50 years and older (10.5% vs 8.4%; P < 0.001) but not emergency surgery (1.8% vs 2.0%; P = 0.52). Patients with complicated disease (abscess, perforation) were at increased risk of readmission than those with uncomplicated disease (12.0% vs 8.2%; P < 0.001), as well as increased risk of emergency surgery (4.3% vs 1.4%, P < 0.001). In multivariable regression, complicated disease and number of prior admissions were associated with increased risk of emergency surgery, yet age less than 50 years was not. Risks associated with complicated disease were nonproportional over time, being highest immediately after discharge and decreasing thereafter., Conclusions: Absolute risks of readmission and emergency surgery are low after nonoperative management of diverticulitis, providing evidence for the practice of deferring colectomy for patients without persistent symptoms or multiple recurrences.

Background: Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates., Study Design: Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology., Results: Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient's comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient's referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication., Conclusions: An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.

Introduction: Non-steroidal anti-inflammatory drugs (NSAIDs) decrease postoperative pain and opioid consumption. The objective of the study was to determine if postoperative NSAIDs were associated with anastomotic leaks following elective colorectal surgery., Materials and Methods: We used a matched nested case-control study design. Using a prospectively collected database, we identified all patients having elective colorectal surgery between January 2001 and June 2012. Cases and matched controls were identified based on the occurrence of a postoperative anastomotic leak. The primary and secondary exposure variables were, respectively, use of any NSAID and use of ketorolac specifically. Conditional logistic regression was used to determine the unadjusted and adjusted odds ratio., Results: A total of 262 patients were included (65.6 % inflammatory bowel disease, 34.4 % cancer). Use of any NSAID was associated with a non-significant increase in anastomotic leaks (odds ratio (OR) 1.81, 95 % confidence interval (CI) 0.98-3.37, p = 0.06). Use of ketorolac was associated with a significant increase in anastomotic leaks (OR 2.09, 95 % CI 1.12-3.89, p = 0.021). There was no significant association between anastomotic leaks and cumulative NSAID dose., Conclusion: These data suggest that there may be an association between NSAIDs and risk of anastomotic leaks after colorectal surgery. Further research is needed to better elucidate this relationship to clarify the implications for patients.

Background: Surgery is a cornerstone of treatment for malignancy. However, significant variation has been reported in patterns and quality of cancer care for important health outcomes, including perioperative mortality. Surgical process improvement tools (SPITs) have been developed that focus on enhancing the processes of care at the point of care, as a means of quality improvement. This study describes SPITs and develops a conceptual framework by synthesizing the available literature on these novel quality improvement tools., Methods: A scoping review was conducted based on instruments developed for quality improvement in surgery. The search was executed on electronically indexed sources (MEDLINE, EMBASE, and the Cochrane library) from January 1990 to March 2011. Data were extracted, tabulated and reported thematically using a narrative synthesis approach. These results were used to develop a conceptual framework that describes and classifies SPITs., Results: 232 articles were reviewed for data extraction and analysis. SPITs identified were classified into 3 groups: clinical mapping tools, structure communication tools and error reduction instruments. The dominant instrument reported were clinical mapping tools, including: clinical pathways (113, 48%), fast track (46, 20%) and enhanced recovery after surgery protocols (36, 15%). Outcomes reported included: length of stay (174, 75%), readmission rates (116, 50%), morbidity (116, 50%), mortality (104, 45%), and economic (60, 26%). Many gaps in the literature were recognized., Conclusion: We have developed a conceptual framework of SPITs and identified gaps in current knowledge. These results will guide the design and development of new quality instruments in surgery.

Background: The aim of this project was to develop a set of quality indicators to assess surgical decision making in the care of patients with non-small cell lung cancer (NSCLC)., Methods: A multidisciplinary Expert Panel of 16 physicians used a modified Delphi process to identify quality indicators that evaluated the processes of care in patients with NSCLC. A systematic review identified potential indicators, which were rated on actionability, validity, usefulness, discriminability, and feasibility in two rounds of questionnaires. The first questionnaire was completed by the Expert Panel and by the larger thoracic surgical community of practice; the second questionnaire was sent to only the Expert Panel. Expert Panel members attended an in-person meeting to review the results of the two questionnaires and to compile the final list of indicators by consensus., Results: From the literature review, 41 potential indicators were identified. An additional 16 indicators were suggested by the Expert Panel: 13 indicators in the two rounds of questionnaires and three after the discussion at the in-person meeting. One further indicator was identified after the in-person meeting. In the end, 17 indicators were chosen from seven domains: preoperative assessment, staging, surgical procedures, pathology, adjuvant therapy, surgical outcomes, and miscellaneous, Conclusions: By use of a modified Delphi process, 17 indicators to assess the quality of processes of surgical care for patients with NSCLC were developed., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: An Enhanced Recovery after Surgery (ERAS) Clinical Practice Guideline (CPG) was developed at the University of Toronto. Before implementation, general surgery residents were surveyed to assess their current stated practices and their perceived barriers and enablers to early discharge., Methods: The survey, which consisted of 33 questions related to the postoperative management of patients undergoing laparoscopic colectomy (LAC), open colectomy (OC) and open low anterior resection (LAR), was distributed to all residents. Chi-square and Fisher exact tests were used to test differences. Open-ended questions were analyzed using content analysis., Results: Of 77 residents surveyed, 58 (75%) responded. Residents stated that a fluid diet would be ordered on POD#0 and regular diet on POD#1 by 67.9% and 49.1%, respectively, following LAC, and 50.0% and 25.9%, respectively, following OC. On POD#1, 89.3% expected patients to ambulate following LAC compared with 67.9% following OC. Residents indicated that urinary catheters would be removed on POD#1 by 87% following LAC and by 81.3% following OC, and by POD#3 by 89.1% following LAR. However, in patients with an epidural, approximately 50% of residents stated that they would wait until it was removed. Overall, 76.4% of residents agreed that an ERAS CPG should be adopted. Residents cited setting expectations, encouragement of early ambulation and feeding, and good pain control as enablers to early discharge. However, patient and family expectations, surgeon preferences, and beliefs of the health care team were mentioned as barriers to early discharge., Conclusion: Residents have a reasonable approach to the management of patients who underwent LAC, but there are gaps that exist in their management, especially following OC and LAR. Although most residents agreed with the implementation of an ERAS CPG, barriers exist, and strategies aimed at ensuring adherence with the recommendations are required., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)