Publications by authors named "Robin S McLeod"

117 Publications

A Public Health Approach to Prevent Firearm Related Injuries and Deaths.

Ann Surg 2021 10;274(4):533-543

Department of Surgery, University of Texas Health Science Center, San Antonio, Texas.

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http://dx.doi.org/10.1097/SLA.0000000000005056DOI Listing
October 2021

Consensus Statement for the Prescription of Pain Medication at Discharge after Elective Adult Surgery.

Can J Pain 2020 Mar 8;4(1):67-85. Epub 2020 Mar 8.

Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

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.
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http://dx.doi.org/10.1080/24740527.2020.1724775DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7951150PMC
March 2020

A Canadian strategy for surgical quality improvement

Can J Surg 2019 12 1;62(6):E16-E18. Epub 2019 Dec 1.

From the University of Toronto, Toronto, Ont. (Urbach, Wei, McLeod); the University of British Columbia, Vancouver, BC (Karimuddin, Hameed); the University of Manitoba, Winnipeg, Man. (Zabolotny); the Canadian Medical Protective Association, Ottawa, Ont. (Lefebvre); Dalhousie University, Halifax, NS (Walsh); McGill University, Montreal, Que. (Fata, Chaudhury); and the Mayo Clinic, Rochester, Minn. (Cleary).

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.
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http://dx.doi.org/10.1503/cjs.019318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6877378PMC
December 2019

Enhanced Recovery After Surgery: Implementation Strategies, Barriers and Facilitators.

Surg Clin North Am 2018 Dec 24;98(6):1201-1210. Epub 2018 Aug 24.

Quality and Best Practices, Department of Surgery, University of Toronto, 149 College Street, 5th Floor, Toronto Ontario M5T 1P5, Canada; Clinical Programs and Quality Initiatives, Cancer Care Ontario, 620 University Avenue, 16th floor, Toronto, ON M5G 2L7, Canada. Electronic address:

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.
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http://dx.doi.org/10.1016/j.suc.2018.07.007DOI Listing
December 2018

Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery: Experience With Implementation of ERAS Across Multiple Hospitals.

Ann Surg 2018 06;267(6):992-997

Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

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.
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http://dx.doi.org/10.1097/SLA.0000000000002632DOI Listing
June 2018

Opioid Use After Discharge in Postoperative Patients: A Systematic Review.

Ann Surg 2018 06;267(6):1056-1062

Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

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.
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http://dx.doi.org/10.1097/SLA.0000000000002591DOI Listing
June 2018

Ready to Go Home? Patients' Experiences of the Discharge Process in an Enhanced Recovery After Surgery (ERAS) Program for Colorectal Surgery.

J Gastrointest Surg 2017 Nov 20;21(11):1865-1878. Epub 2017 Sep 20.

Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.

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.
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http://dx.doi.org/10.1007/s11605-017-3573-0DOI Listing
November 2017

Emergency Room Visits and Readmissions Following Implementation of an Enhanced Recovery After Surgery (iERAS) Program.

J Gastrointest Surg 2018 02 15;22(2):259-266. Epub 2017 Sep 15.

Department of Surgery, University of Toronto, Toronto, Ontario, Canada.

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.
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http://dx.doi.org/10.1007/s11605-017-3555-2DOI Listing
February 2018

Compliance with Urinary Catheter Removal Guidelines Leads to Improved Outcome in Enhanced Recovery After Surgery Patients.

J Gastrointest Surg 2017 08 25;21(8):1309-1317. Epub 2017 May 25.

Department of Surgery, University of Toronto, Toronto, ON, Canada.

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.
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http://dx.doi.org/10.1007/s11605-017-3434-xDOI Listing
August 2017

Quality Improvement Initiatives in Colorectal Surgery: Value of Physician Feedback.

Authors:
Robin S McLeod

Dis Colon Rectum 2017 Feb;60(2):133-134

Toronto, Ontario, Canada.

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http://dx.doi.org/10.1097/DCR.0000000000000756DOI Listing
February 2017

Preoperative Anti-tumor Necrosis Factor Therapy in Patients with Ulcerative Colitis Is Not Associated with an Increased Risk of Infectious and Noninfectious Complications After Ileal Pouch-anal Anastomosis.

Inflamm Bowel Dis 2016 10;22(10):2442-7

*Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; †Institute of Gastroenterology and Liver Diseases, Emek Medical Center, Afula, Israel; ‡Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ontario, Canada; §Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; and ‖Mount Sinai Hospital, Division of General Surgery, University of Toronto, Toronto, Ontario, Canada.

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.
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http://dx.doi.org/10.1097/MIB.0000000000000919DOI Listing
October 2016

Understanding Perioperative Transfusion Practices in Gastrointestinal Surgery-a Practice Survey of General Surgeons.

J Gastrointest Surg 2016 06 29;20(6):1106-22. Epub 2016 Mar 29.

Division of General Surgery, University of Toronto, Toronto, ON, Canada.

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.
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http://dx.doi.org/10.1007/s11605-016-3111-5DOI Listing
June 2016

Clinical practice guideline: management of acute pancreatitis.

Can J Surg 2016 Apr;59(2):128-40

From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont.

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.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4814287PMC
http://dx.doi.org/10.1503/cjs.015015DOI Listing
April 2016

The Decline of Elective Colectomy Following Diverticulitis: A Population-Based Analysis.

Dis Colon Rectum 2016 Apr;59(4):332-9

1 Department of Surgery, University of Toronto, Toronto, Ontario, Canada 2 Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada 3 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 4 Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada 5 Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada 6 Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada 7 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada 8 Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

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.
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http://dx.doi.org/10.1097/DCR.0000000000000561DOI Listing
April 2016

Modified Two-stage Ileal Pouch-Anal Anastomosis Results in Lower Rate of Anastomotic Leak Compared with Traditional Two-stage Surgery for Ulcerative Colitis.

J Crohns Colitis 2016 Jul 7;10(7):766-72. Epub 2016 Mar 7.

Zane Cohen Centre for Digestive Disease, Mount Sinai Hospital, Toronto, ON, Canada, Division of General Surgery, University of Toronto, Toronto, ON, Canada.

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.
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http://dx.doi.org/10.1093/ecco-jcc/jjw069DOI Listing
July 2016

Successful implementation of an enhanced recovery after surgery programme for elective colorectal surgery: a process evaluation of champions' experiences.

Implement Sci 2015 Jul 17;10:99. Epub 2015 Jul 17.

Department of Surgery, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, M5T 1P5, Canada.

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.
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http://dx.doi.org/10.1186/s13012-015-0289-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4504167PMC
July 2015

Predictors of Outcome in Ulcerative Colitis.

Inflamm Bowel Dis 2015 Sep;21(9):2097-105

*Zane Cohen Centre for Digestive Diseases, Division of Gastroenterology, Mount Sinai Hospital, Toronto, ON, Canada; †Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel; ‡Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Neuroscience Research, Toronto, ON, Canada; §University of Toronto, Toronto, ON, Canada; ||Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; and ¶Department of Surgery, Mount Sinai Hospital, Toronto, ON, Canada.

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.
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http://dx.doi.org/10.1097/MIB.0000000000000466DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157811PMC
September 2015

Prevalence of Physiologic Sexual Dysfunction Is High Following Treatment for Rectal Cancer: But Is It the Only Thing That Matters?

Dis Colon Rectum 2015 Aug;58(8):736-42

1 Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada 2 Zane Cohen Centre for Digestive Diseases, Toronto, Ontario, Canada 3 Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada 4 Department of Diagnostic Assessment, Grand River Hospital, Kitchener, Ontario, Canada 5 Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada 6 Keenan Research Centre, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada 7 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

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.
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August 2015

Development of an Enhanced Recovery After Surgery Guideline and Implementation Strategy Based on the Knowledge-to-action Cycle.

Ann Surg 2015 Dec;262(6):1016-25

*Department of Surgery, Mount Sinai Hospital, New York, NY †Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada ‡Department of Surgery, Toronto East General Hospital, Toronto, Ontario, Canada §Department of Anaesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada ¶Anesthesia, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada ||Department of Surgery, McMaster University, Hamilton, Ontario, Canada **Departments of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada ††Department of Surgery, University Health Network, Toronto, Ontario, Canada ‡‡Nursing, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada.

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.
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December 2015

SSAT presidential address 2014: here comes Generation Y!

Authors:
Robin S McLeod

J Gastrointest Surg 2015 Jan 13;19(1):1-5. Epub 2014 Dec 13.

Department of Surgery, University of Toronto, Toronto, Canada,

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January 2015

Evolving practice patterns in the management of acute colonic diverticulitis: a population-based analysis.

Dis Colon Rectum 2014 Dec;57(12):1397-405

1Department of Surgery, University of Toronto, Toronto, Ontario, Canada 2Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 4Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada 5Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada 6Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada 7Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada 8Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

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.
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December 2014

Subtotal colectomy in severe ulcerative and Crohn's colitis: what benefit does the laparoscopic approach confer?

Dis Colon Rectum 2014 Dec;57(12):1349-57

1Division of General Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada 2Zane Cohen Clinical Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada 3Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada 4Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada 5Department of Surgery, University of Toronto, Toronto, Ontario, Canada 6Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.

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).
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December 2014

Proctocolectomy for colorectal cancer--is the ileal pouch anal anastomosis a safe alternative to permanent ileostomy?

Int J Colorectal Dis 2014 Dec 17;29(12):1485-91. Epub 2014 Oct 17.

Department of Surgery, University of Toronto, Toronto, ON, Canada.

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.
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December 2014

A multifaceted knowledge translation strategy can increase compliance with guideline recommendations for mechanical bowel preparation.

J Gastrointest Surg 2015 Jan 20;19(1):39-44; discussion 44-5. Epub 2014 Sep 20.

Department of Surgery, McMaster University, Hamilton, ON, Canada.

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).
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January 2015

Risk of readmission and emergency surgery following nonoperative management of colonic diverticulitis: a population-based analysis.

Ann Surg 2014 Sep;260(3):423-30; discussion 430-1

*Department of Surgery, University of Toronto, Toronto, Ontario, Canada †Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada ‡Department of Surgery, Institute of Health Policy, Management and Evaluation, Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada §Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada ¶Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada ‖Department of Family and Community Medicine, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; and **Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.

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.
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September 2014

Improving quality through process change: a scoping review of process improvement tools in cancer surgery.

BMC Surg 2014 Jul 19;14:45. Epub 2014 Jul 19.

Princess Margaret Cancer Centre, University Health Network, Department of Surgery, University of Toronto, Toronto, ON, Canada.

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.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112620PMC
July 2014

NSAID use and anastomotic leaks following elective colorectal surgery: a matched case-control study.

J Gastrointest Surg 2014 Aug 10;18(8):1391-7. Epub 2014 Jun 10.

Division of General Surgery, Department of Surgery, Mount Sinai Hospital, University of Toronto, 600 University Avenue, Suite 1220, Toronto, ON, M5G 1X5, Canada.

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.
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August 2014

Identification of process measures to reduce postoperative readmission.

J Gastrointest Surg 2014 Aug 10;18(8):1407-15. Epub 2014 Jun 10.

Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North St. Clair, Suite 650, Chicago, IL, 60611, USA,

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.
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August 2014

Understanding surgical residents' postoperative practices and barriers and enablers to the implementation of an Enhanced Recovery After Surgery (ERAS) Guideline.

J Surg Educ 2014 Jul-Aug;71(4):632-8. Epub 2014 May 5.

Division of General Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada; Zane Cohen Clinical Research Centre, Mount Sinai Hospital, Toronto, Ontario, Canada; Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada; Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Electronic address:

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.
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April 2015

Development and implementation of a synoptic MRI report for preoperative staging of rectal cancer on a population-based level.

Dis Colon Rectum 2014 Jun;57(6):700-8

1Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada 2Zane Cohen Centre for Digestive Diseases, Toronto, Ontario, Canada 3Department of Medicine, University of Toronto, Toronto, Ontario, Canada 4Institute of the Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada 5Department of Medical Imaging, Sunnybrook Health Science Centre, Toronto, Ontario, Canada 6Department of Medical Imaging, Saint Joseph's Health Centre, Toronto, Ontario, Canada 7Department of Medical Imaging, The Royal Marsden Hospital, London, United Kingdom 8Samuel Lunenfeld Research Institute, Toronto, Ontario, Canada.

Background: Colorectal cancer physician champions across the province of Ontario, Canada, reported significant concern about appropriate selection of patients for preoperative chemoradiotherapy because of perceived variation in the completeness and consistency of MRI reports.

Objective: The purpose of this work was to develop, pilot test, and implement a synoptic MRI report for preoperative staging of rectal cancer.

Design: This was an integrated knowledge translation project.

Settings: This study was conducted in Ontario, Canada.

Patients: Surgeons, radiologists, radiation oncologists, medical oncologists, and pathologists treating patients with rectal cancer were included in this study.

Interventions: A multifaceted knowledge translation strategy was used to develop, pilot test, and implement a synoptic MRI report. This strategy included physician champions, audit and feedback, assessment of barriers, and tailoring to the local context. A radiology webinar was conducted to pilot test the synoptic MRI report.

Main Outcome Measures: Seventy-three (66%) of 111 Ontario radiologists participated in the radiology webinar and evaluated the synoptic MRI report.

Results: A total of 78% and 90% radiologists expressed that the synoptic MRI report was easy to use and included all of the appropriate items; 82% noted that the synoptic MRI report improved the overall quality of their information, and 83% indicated they would consider using this report in their clinical practice. An MRI report audit after implementation of the synoptic MRI report showed a 39% improvement in the completeness of MRI reports and a 37% uptake of the synoptic MRI report format across the province.

Limitations: Radiologists evaluating the synoptic MRI report and participating in the radiology webinar may not be representative of gastroenterologic radiologists in other geographic jurisdictions. The evaluation of completeness and uptake of the synoptic MRI reports is limited because of unmeasured differences that may occur before and after the MRI.

Conclusions: A synoptic MRI report for preoperative staging of rectal cancer was successfully developed and pilot tested in the province of Ontario, Canada.
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June 2014
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