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Background: To determine the role of liver resection in patients with liver and extrahepatic colorectal cancer metastases and the role of chemotherapy in patients in conjunction with liver resection., Methods: MEDLINE and EMBASE databases were searched for articles published between 1995 and 2010, along with hand searching., Results: A total of 4875 articles were identified, and 83 were retained for inclusion. Meta-analysis was not performed because of heterogeneity and poor quality of the evidence. Outcomes in patients who had liver and lung metastases, liver and portal node metastases, and liver and other extrahepatic disease were reported in 14, 10, and 14 studies, respectively. The role of perioperative chemotherapy was assessed in 30 studies, including 1 randomized controlled trial and 1 pooled analysis. Ten studies assessed the role of chemotherapy in patients with initially unresectable disease, and 5 studies assessed the need for operation after a radiologic complete response., Conclusion: The review suggests that: (1) select patients with pulmonary and hepatic CRC metastases may benefit from resection; (2) perioperative chemotherapy may improve outcome in patients undergoing a liver resection; (3) patients whose CRC liver metastases are initially unresectable may benefit from chemotherapy to identify a subgroup who may benefit later from resection; (4) after radiographic complete response (RCR), lesions should be resected if possible., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: Previous studies have shown that practices supported by level I evidence may take up to 20 years before they are adopted. Although mechanical bowel preparation (MBP) has been a routine practice in colorectal surgery, there is strong evidence dating back to the early 1990s suggesting that in most patients MBP before elective colorectal surgery is not required. The objective of this study was to determine if surgical practices pertaining to bowel preparation could be altered using a tailored knowledge translation strategy., Methods: A multi-faceted strategy including guideline development, consensus, education by opinion leaders, audit and feedback, and reminder cards was used in this before-after study. The primary outcome was compliance with the recommendations presented in the guideline regarding MBP, normal diet on the day prior to surgery, and enemas., Results: Two-hundred eighty-two patients were enrolled in the study with 111 enrolled before the intervention and 171 enrolled after the intervention. Demographic and clinical characteristics between the 2 groups were similar. Overall, there was a 7.8% increase in compliance with MBP recommendations (81.1% vs 88.4%, P = .038), a 10.2% increase in compliance with diet recommendations (45.6% vs 55.8%, P = .080), and a 5.6% increase in compliance with enema recommendations (88.5% vs 94.2%, P < .001)., Conclusion: The results of this study reveal that a tailored, multi-faceted knowledge translation strategy is effective in changing surgeon behavior., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: Little is known about the postoperative status and support needs of patients undergoing colorectal cancer operations. The objective of this study was to describe the disposition and resource use of Ontario's elderly population undergoing colorectal cancer operations as well as to identify predictors of outcomes using population-based data., Methods: A total of 33,238 patients aged 50 years and older with a diagnosis of colorectal cancer were identified using International Classification of Diseases 9 and 10 codes in the Ontario Cancer Registry linked to procedure codes in the Canadian Institute for Health Information Discharge Abstract Database representing colorectal operations within 6 months of diagnosis from 1997 to 2004. Data on an individual's home-care use were collected from the Ontario Home Care Administrative System. The cohort was divided into the following age groups: 50-64 years, 65-74 years, 75-79 years, and 80 years and older. The primary outcomes assessed were postoperative mortality, length of stay, discharge disposition, need for home care, and readmission within 30 days., Results: Based on univariate and multivariate analyses, patients aged 75-79 years and 80 years and older were more likely to die in hospital (odds ratio 2.84; 95% confidence interval 2.32-3.47 and odds ratio 5.72; 95% confidence interval 4.76-6.88), stay longer in hospital (2.78 [standard error 0.22] and 5.16 [standard error 0.19] days, respectively), not return home (odds ratio 5.62; confidence interval 3.99-7.98 and odds ratio 11.59; confidence interval 8.32-16.13), receive home care (odds ratio 1.44; 95% confidence interval 1.34-1.55 and odds ratio 1.71; 95% confidence interval 1.59-1.83), and be readmitted (odds ratio 1.31; 95% confidence interval 1.19-1.45 and odds ratio 1.59; 95% confidence interval 1.44-1.75) compared with younger individuals. The rate of discharge home for patients aged 80 years and older was more than 78%. Factors predisposing patients older than 75 years to poorer outcomes were higher Charlson comorbidity score, urgent admission, construction of a stoma, and reoperation., Conclusion: Although discharge-related outcomes worsen with age, most elderly patients do well and can return home after a colorectal cancer operation. Elderly patients require more support; therefore, discharge planning should be part of preoperative assessment and discussions., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: The effectiveness of interventions for developing critical appraisal skills in practicing physicians has not been studied, despite the documented importance of reading the literature in caring for patients and in continuing professional development. The objective of this study was to evaluate whether an Internet-based intervention would lead to enhanced critical appraisal skills in practicing surgeons., Methods: General surgeons who agreed to participate were randomized into 2 groups. The intervention was a curriculum in critical appraisal skills that included a clinical and methodologic article, a listserve discussion, and clinical and methodologic critiques. The control group received only the clinical articles. The primary outcome measure was a previously validated 2-hour test of critical appraisal., Results: Of the 55 surgeons who completed the examination, subjects in the intervention group performed better on the test of critical appraisal skills than those in the control group (mean score: intervention group, 58% +/- 8 vs control group, 50% +/- 8), with a large effect size of 1.06 standard deviation units (t+3.92, P <.0001). Training conditions accounted for 22% of the variance in total scores., Conclusions: A multifaceted, Internet-based intervention resulted in improved critical appraisal skills of practicing general surgeons.

Background: The objective of this study was, first to determine what proportion of clinical treatment evaluation questions involving surgical operations could be answered by a randomized controlled trial (RCT). Second, for those questions not amenable to a RCT, to determine the problems that potentially preclude the initiation of RCT in an ideal clinical research setting., Methods: A sample of treatment evaluation questions involving a surgical procedure was obtained by a computerized search of the surgical literature. Problems precluding a RCT were defined. Their face validity and interobserver and intraobserver reliability were assessed. By use of these criteria, the sample questions were evaluated to determine whether a RCT could be performed and, if not, the predominant reasons precluding RCT of surgical procedures., Results: Only 38.8% of treatment evaluation questions could have been answered by a RCT in an ideal clinical research setting. Patient preference was the most common precluding problem encountered (40% of all problems). The principal precluding problem was patient preference in 23.1%, an uncommon condition in 24.2%, and lack of community (clinical) equipoise in 10%. Methodologic issues (1.2%) and surgical preference (2.3%) were infrequent precluding problems. Questions evaluating therapy for malignant disease, comparing surgical with nonsurgical therapies, and where survival was the primary outcome were more likely to have problems precluding RCT., Conclusions: In the ideal situation RCT can be performed to evaluate only 40% of treatment questions involving surgical procedures. Patient preferences, uncommon conditions, and lack of surgical community equipoise appear to be the most common reasons precluding the of RCT of surgical operations.

Background: The objective was to determine the number of randomized controlled trials (RCT) performed by surgeons, published in surgical journals, or comprising a surgical arm and to assess their characteristics and overall quality., Methods: RCT in general surgery (including gastrointestinal, breast, surgical oncology, vascular, critical care, and trauma) published in 1990 were retrieved by MEDLINE and analyzed to determine the funding agency, type of therapy, area of surgery, journal published, country of origin, number of centers, and whether a surgeon was the principal author. The completeness of the MEDLINE search was compared to a manual search of the literature. All RCT were assessed with Chalmers' qualitative score., Results: MEDLINE retrieved 202 surgical RCT (46% of those retrieved by a manual search) with a mean score of 0.40 +/- 0.13. However, surgical RCT were performed by surgeons in only one third of trials, compared surgical therapies in only one quarter of trials, and were published in surgical journals in less than one third of trials. Only 22% of surgical RCT were funded by peer reviewed granting agencies. The strongest variables determining the quality of surgical RCT were the type of therapy tested (p = 0.0001), the type of journal published (p = 0.006), and the area of general surgery (p = 0.007)., Conclusions: Although surgical RCT are being performed, there are a relatively low proportion and standard of RCT performed by surgeons as the principal author, published in surgical journals, and comparing surgical therapies. This may reflect a lack of expertise by surgeons in clinical trials, lack of funding for surgical trials, methodologic problems peculiar to surgical trials, or a need for adoption of other research designs to assess surgical therapies.

A randomized, controlled trial was performed to determine whether infiltration of fascia with bupivacaine, a long-acting local anesthetic, at the time of closure after elective laparotomy, is effective in preventing postoperative respiratory complications. At the Toronto General Hospital 415 patients undergoing elective laparotomy were randomly allocated to receive bupivacaine 0.25% (2 ml/cm incision), infiltrated into the fascia evenly along both sides of the incision before wound closure (202 patients), or to have closure without infiltration (213 patients). Chest x-ray (CXR) films of all patients were obtained preoperatively and on the second postoperative day. Pulmonary function studies were performed preoperatively and for the first two consecutive days postoperatively. CXR films were scored by a blinded observer. Postoperatively, 64% of the treatment group and 56% of the control group had evidence of atelectasis on CXR films (p = NS, chi 2 test). Both groups had similar decrements in vital capacity and expiratory reserve volume on the first and second postoperative days. There was no significant difference in the amount of analgesic taken in the first 24 hours, although the time to first analgesic was significantly longer in the treatment group (2.2 vs 1.3 hours, p less than 0.055). We conclude that infiltration of the fascia with 0.25% bupivacaine at a dose of 2 ml/cm of incision is not effective in preventing postoperative atelectasis. It does not reduce use of an analgesic although it may delay its initial requirement.