The impact of surgery for colorectal cancer on quality of life and functional status in the elderly

PURPOSE

Colorectal cancer is a common diagnosis in the elderly. Frequently concerns arise about outcomes after surgery, and little is known about postoperative quality of life in this older group after major bowel surgery. The objective of this study was to compare quality of life and functional status of elderly patients (older than aged 80 years) who have undergone surgery for colorectal cancer with a younger (younger than aged 70 years), procedure-matched control group.

METHODS

Patients in the case (older than aged 80 years) and control groups (younger than aged 70 years) were identified from the colorectal cancer database at Mount Sinai Hospital, Toronto, Canada. All had treatment for colorectal cancer within the last five years. Patients were surveyed by mail using the European Organization for Research and Treatment of Cancer quality of life scales specific to cancer and colorectal cancer (EORTC-C30 and EORTC-CR38) and the Short Form-36. Student's t-test was used to test differences.

RESULTS

There were 29 patients in each of the groups. The current average ages were 83.2 (standard deviation=2.79) years, and 67.7 (standard deviation=5.1) years, respectively. The two groups scored similarly on the European Organization for Research and Treatment of Cancer quality of life scales in all domains except physical functioning, functional role, micturition, and stoma-related problems. Similarly, the mean scores of the Short Form-36 were similar with the exception of the vitality domain. Most patients did not require special assistance or alternate living arrangements after discharge from the hospital, and most patients seemed to be able to return to their preoperative level of functioning. However, stoma care was a greater concern to the elderly.

CONCLUSIONS

Elderly patients older than aged 80 years who are selected for surgery have a quality of life comparable to younger patients in most respects. Therefore, colorectal cancer surgery may be offered to the highly functioning elderly with the expectation of a good quality of life postoperatively.

Reliability and validity of the body image after breast cancer questionnaire

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.

Increased experience and surgical technique lead to improved outcome after ileal pouch-anal anastomosis: a population-based study

PURPOSE

This study was designed to determine whether changes in length of stay and 30-day readmission, reoperation, and excision rates for the ileal pouch-anal anastomosis occurred over time and with changes in surgical technique and hospital volume.

METHODS

Using three population-based administrative databases, data on all ileal pouch-anal anastomoses performed in the province of Ontario between January 1992 and June 1998 were obtained. The effect of age, gender, stage of the procedure, year of surgery, and hospital volume were examined for their effect on length of stay and readmission, reoperation, and excision rates.

RESULTS

There were 1,285 ileal pouch-anal anastomoses performed in 58 hospitals. There was a significant decrease in length of stay and reoperation and excision rates but a concommitant increase in readmission rate during the study period. Patients younger than aged 40 years had a significantly lower length of stay and excision rate. Patients who had a two-stage procedure had a shorter length of stay, readmission, and reoperative rate compared with those having a three-stage procedure. Hospital volume was a significant predictor of need for reoperation and excision with both low-volume and medium-volume hospitals having significantly higher rates than high-volume hospitals.

CONCLUSIONS

Outcome after ileal pouch-anal anastomosis has improved. It is significantly better in patients younger than aged 40 years, having a two-stage procedure, and where surgery is performed at high-volume hospitals. It is likely that both modifications in surgical technique and surgical experience have led to improvements in clinical outcome after ileal pouch-anal anastomosis.

Phenotype-stratified genetic linkage study demonstrates that IBD2 is an extensive ulcerative colitis locus

OBJECTIVES

The complete elucidation of genetic variants that contribute to inflammatory bowel disease (IBD) will likely include variants that increase risk to both Crohn's disease and ulcerative colitis as well as variants that increase risk for particular phenotypic subsets. The purpose of this study was to assess phenotypic subsets that contribute to the major IBD susceptibility loci.

METHODS

This linkage study encompassed 904 affected relative pairs, representing the largest combined phenotyped cohort to date, and allowing for meaningful subset analyses. Genetic linkage data were stratified by disease location and age at diagnosis.

RESULTS

We establish that some loci, notably the IBD3 and chromosome 3q linkage regions demonstrate contributions from both small intestine and colon cohorts, whereas others, notably the IBD1 (NOD2/CARD15) and IBD2 regions increase risk for small intestine or colon inflammation, respectively. The strongest linkage evidence in this study was for the subset of extensive ulcerative colitis in the region of IBD2 (lod 3.27; p < 0.001). Evidence for linkage in the region of NOD2/CARD15 (IBD1) was stronger for the subset of Crohn's patients with ileal disease (lod 2.56; p= 0.035) compared to the overall Crohn's group, consistent with previous findings that NOD2/CARD15 variants are associated with ileal disease.

CONCLUSIONS

Analyses incorporating disease location in IBD increase the power and enhance the accuracy of genomic localization. Our data provide strong evidence that extensive ulcerative colitis represents a pathophysiologic subset of IBD.

Surveillance colonoscopy in individuals at risk for hereditary nonpolyposis colorectal cancer: an evidence-based review

PURPOSE

Surveillance colonoscopy plays an important role in the management of asymptomatic patients known to carry and suspected of carrying hereditary nonpolyposis colorectal cancer gene mutations. Although the shortest interval between surveillance examinations may seem to offer the most benefit to patients, excessive use of this procedure may have unwanted consequences. This study was designed to evaluate the evidence and make recommendations regarding the optimal frequency of surveillance colonoscopy and the age at which to initiate surveillance based on the best available evidence.

METHODS

MEDLINE was searched for all articles assessing surveillance colonoscopy from 1966 to 2004 by using the MESH terms "hereditary nonpolyposis colorectal cancer" and "screening." The evidence was systematically reviewed and a critical appraisal of the evidence was performed.

RESULTS

There are no randomized, controlled, clinical trials examining the frequency of surveillance colonoscopy in hereditary nonpolyposis colorectal cancer. Three cohort studies were identified for review. There is one cohort study of good quality that provides evidence that surveillance colonoscopy every three years in patients with hereditary nonpolyposis colorectal cancer reduces the risk of developing colorectal cancer and the risk of death. The two remaining cohort studies provide poor evidence on which to make a recommendation.

CONCLUSIONS

The best available evidence supports surveillance with complete colonoscopy to the cecum every three years in patients with hereditary nonpolyposis colorectal cancer (B recommendation). There is no evidence to support or refute more frequent screening. Further research is required to examine the potential harms and benefits of more frequent screening. However, given the potential for rapid progression from adenoma to carcinoma and missing lesions at colonoscopy, there is consensus that screening more frequently than every three years is required.

Prevalence of male and female sexual dysfunction is high following surgery for rectal cancer

OBJECTIVE

To measure sexual function and quality of life (QOL) after rectal cancer treatment.

SUMMARY BACKGROUND DATA

Previous studies on sexual function after rectal cancer treatment have focused on males and have not used validated instruments.

METHODS

Patients undergoing curative rectal cancer surgery from 1980 to 2003 were administered a questionnaire, including the Female Sexual Function Index (FSFI) or International Index of Erectile Function (IIEF), and the EORTC QLQ-C30/CR-38. Multiple logistic regression was used to test associations of clinical factors with outcomes.

RESULTS

Eighty-one women (81.0%) and 99 men (80.5%) returned the questionnaire; 32% of women and 50% of men are sexually active, compared with 61% and 91% preoperatively (P < 0.04); 29% of women and 45% of men reported that "surgery made their sexual lives worse." Mean (SD) FSFI and IIEF scores were 17.5 (11.9) and 29.3 (22.8). Specific sexual problems in women were libido 41%, arousal 29%, lubrication 56%, orgasm 35%, and dyspareunia 46%, and in men libido 47%, impotence 32%, partial impotence 52%, orgasm 41%, and ejaculation 43%. Both genders reported a negative body image. Patients seldom remembered discussing sexual risks preoperatively and seldom were treated for dysfunction. Current age (P < 0.001), surgical procedure (P = 0.003), and preoperative sexual activity (P = 0.001) were independently associated with current sexual activity. Gender (male, P = 0.014), surgical procedure (P = 0.005), and radiation therapy (P = 0.0001) were independently associated with the outcome "surgery made sexual life worse." Global QOL scores were high.

CONCLUSIONS

Sexual problems after surgery for rectal cancer are common, multifactorial, inadequately discussed, and untreated. Therefore, sexual dysfunction should be discussed with rectal cancer patients, and efforts to prevent and treat it should be increased.

Crohn's disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure

PURPOSE

This study was designed to determine the outcome of patients with Crohn's disease and indeterminate colitis who have an ileal pouch-anal anastomosis.

METHODS

Between 1982 and 2001, 1,270 patients underwent a restorative proctocolectomy at the Mount Sinai Hospital: 1,135 had ulcerative colitis, 36 had Crohn's disease, 21 had indeterminate colitis, and 78 had another diagnosis. Perioperative data were collected prospectively. Functional outcomes were assessed with a 35-question survey mailed to all patients with a functioning pouch of at least six months duration.

RESULTS

Pouch complications were significantly more common in patients with Crohn's disease (64 percent) and indeterminate colitis (43 percent) compared with patients with ulcerative colitis (22 percent) (P < 0.05). Similarly, 56 percent of patients with Crohn's disease had their pouch excised or defunctioned, compared with 10 percent of patients with indeterminate colitis and 6 percent with ulcerative colitis (P < 0.01). In the subgroup of patients with a diagnosis of Crohn's disease, multivariate analysis revealed that the pathologist's initial designation of ulcerative colitis (based on the colectomy specimen) and an increasing number of pathologic, clinical, and endoscopic features of Crohn's disease were independently associated with pouch failure. The functional results in patients with Crohn's disease with a successful pouch were not significantly different from those with indeterminate colitis or ulcerative colitis.

CONCLUSIONS

Although complication rates may be higher in patients with indeterminate colitis compared with ulcerative colitis, the overall pouch failure rate is similar. On the other hand, more than one-half of patients with Crohn's disease will require pouch excision or diversion. Our data suggest that it is difficult to identify patients with Crohn's disease who are likely to have a successful outcome after restorative proctocolectomy. Thus, Crohn's disease should remain a relative contraindication to restorative proctocolectomy, whereas ileal pouch-anal anastomosis is an acceptable alternative for patients with indeterminate colitis.

Pouch-vaginal fistula after ileal pouch-anal anastomosis: treatment and outcomes

PURPOSE

Pouch-vaginal fistula is an uncommon but serious complication after ileal pouch anal anastomosis. The management of pouch-vaginal fistulas is challenging and a number of treatment options exist. The purpose of this study was to examine the outcomes after various procedures for pouch-vaginal fistula performed at our institution.

METHODS

Patients who were treated for pouch-vaginal fistula at Mount Sinai Hospital were identified from a prospectively maintained database. Demographic, disease history, treatment, and outcomes data were obtained. Treatment success was defined as no recurrence of the fistula with a functioning pouch and no ileostomy.

RESULTS

Since November 1982, 24 of 619 (3.9 percent) women who had primary ileal pouch-anal anastomosis performed at Mount Sinai Hospital developed a pouch-vaginal fistula. Five women had ileal pouch-anal anastomosis performed at another institution and were referred for management of their pouch-vaginal fistula. Local and/or combined abdominoperineal repairs were performed in 22 of 29 patients. Combined abdominoperineal repairs were associated with a higher success rate than that of local perineal repairs (52.9 vs. 7.9 percent, respectively, at 10 years after repair; p = 0.035). Overall, 50 percent (11/22) of patients who underwent surgical repair of a pouch-vaginal fistula had a successful result with a functioning pouch and no recurrence of the fistula, and 21 percent (6/29) of patients required pouch excision.

CONCLUSIONS

The management of pouch-vaginal fistula after ileal pouch-anal anastomosis is associated with a high recurrence rate. Combined abdominoperineal repair appears to offer better results than those of local procedures.

Azathioprine or ileocolic resection for steroid-dependent terminal ileal Crohn's disease? A Markov analysis

INTRODUCTION

The objective of this study was to determine whether initial azathioprine therapy, followed by ileocolic resection if azathioprine fails, or initial ileocolic resection without a trial of azathioprine is the preferred treatment strategy in steroid-dependent, terminal ileal Crohn's disease.

METHODS

A Markov, decision analytic model was developed to simulate a 36-month course for a patient with steroid-dependent, terminal ileal Crohn's disease who would initially take azathioprine or have ileocolic resection. Clinically important outcomes in the model included side effects and effectiveness of azathioprine and postoperative complications, mortality, and recurrence following ileocolic resection. The probabilities and utilities for these variables were derived from previously published studies.

RESULTS

Initial azathioprine therapy offered a relatively small benefit of 0.45 quality-adjusted life-months over initial ileocolic resection. The model was sensitive to utility for being symptom-free on azathioprine and utility for being symptom-free postoperatively.

CONCLUSIONS

Initial azathioprine therapy and initial ileocolic resection are both reasonable treatment strategies in this setting. The preferred treatment strategy is highly dependent on the quality of life that can be achieved with each treatment option. Therefore, individual response and symptom control with each treatment must be strongly considered in this treatment decision.

Teaching practicing surgeons critical appraisal skills with an Internet-based journal club: A randomized, controlled trial

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.

Surgical management of entero and colocutaneous fistulae in Crohn's disease: 17 year's experience

BACKGROUND AND AIMS

Fistulous disease is common in Crohn's disease, and entero- and colocutaneous fistulae are particularly debilitating and difficult to manage. We present the results of surgical management of these fistulas.

PATIENTS AND METHODS

Retrospective chart review of all 51 patients with Crohn's disease (56 surgical procedures) undergoing surgery for cutaneous fistulae between 1983 and 2000.

RESULTS

Previous surgery for Crohn's disease had been carried out in 43 patients (84%). The fistula site was enterocutaneous in 36 patients (64%), colocutaneous in 12 (21%), and anastomotic in 8 (14%); 9 patients (16%) also had associated enteroenteric fistulas. The onset of the fistula followed abscess drainage in 15 (27%) and occurred at the site of recurrent disease in 41 (73%). Forty patients (71%) initially underwent conservative management prior to surgery; 16 (28%) underwent surgery directly. Surgical procedures were: 25 ileocolic resections, 8 stoma revisions with resection, 8 small bowel resections 7 subtotal colectomies, 4 partial colectomies, 3 proctocolectomies, and one fistula tract excision. Mean total length of stay was 18 days (postoperative 10.7 days). Six (11%) patients had eight postoperative complications. Mean follow-up was 48.6 months (range 3-187). Recurrence as defined by either clinical examination or reoperation was documented in nine fistulas (16%), with a mean time to recurrence of 27 months.

CONCLUSION

Entero-and colocutaneous fistulae usually occur from a site of active disease. Surgical management with bowel resection, including the fistula, is the preferred method of treatment. Morbidity has been low and recurrence rate lower than expected.

Nonsteroidal anti-inflammatory drugs and aspirin for the prevention of colorectal adenomas and cancer: a systematic review

PURPOSE

A systematic review was conducted to determine the effect of nonsteroidal anti-inflammatory drugs for the prevention or regression of colorectal adenomas and cancer.

METHODS

Randomized, controlled trials through September 2003 were identified. Nonsteroidal anti-inflammatory drugs were the interventions. The primary outcomes were the number of patients with at least one colorectal adenoma, a change in polyp burden, or colorectal cancer. The secondary outcome was adverse events. Two reviewers independently extracted data and assessed trial quality. Dichotomous outcomes were reported as relative risks with 95 percent confidence intervals. The data were combined if clinically and statistically reasonable.

RESULTS

Nine trials with 150 familial adenomatous polyposis and 24,143 population patients met the inclusion criteria. The interventions included sulindac, celecoxib, or aspirin. From the combined results of three trials, significantly fewer patients in the aspirin group developed recurrent sporadic colorectal adenomas (relative risk, 0.77 (95 percent confidence interval, 0.61, 0.96), number needed to treat 12.5 (95 percent confidence interval, 7.7, 25)) after one to three years. In another three trials, patients with familial adenomatous polyposis who received nonsteroidal anti-inflammatory drugs had a greater proportional reduction (range, 11.9-44 percent) in the number of colorectal adenomas compared with those in the control group (range, 4.5-10 percent). There was no significant difference for the outcomes of colorectal cancer or adverse events in any of the trials.

CONCLUSIONS

There is combined evidence from three randomized trials that aspirin significantly reduced the recurrence of sporadic adenomatous polyps. There was evidence from short-term trials to support regression, but not elimination or prevention, of colorectal polyps in familial adenomatous polyposis.

Current awareness in Canada of clinical practice guidelines for colorectal cancer screening

INTRODUCTION

The Canadian Task Force on Preventive Health Care (CTF-PHC) recently revised its screening recommendations for colorectal cancer (CRC). We wished to assess the effect of this change on the screening beliefs and clinical practice of primary care physicians.

METHODS

We surveyed 160 primary-care physicians, quasi-randomly sampled, in June-July 2001 and again in April-July 2002, 9 months after publication of the guidelines. Descriptive statistics and McNemar chi2 analyses were carried out on data from physicians who responded to both surveys.

RESULTS

Of the those sampled, 47% responded to both surveys. After the publication of the CTF-PHC guidelines, the proportion reporting that they recommend CRC screening to their patients at average risk increased from 43% to 60% (p = 0.02). Before publication of the revised guidelines 48% stated that the CTF-PHC did not support screening, compared with 24% afterward (p = 0.01). CTF-PHC guidelines were acknowledged by 30% to be a source of CRC screening information. Around 9 months post-publication, 24% of the physicians stated their awareness of the revised screening guidelines. The most commonly cited reasons for not recommending CRC screening to average-risk patients were that the evidence is inconclusive and that CTF-PHC guidelines do not support screening.

CONCLUSIONS

After publication of the revised CTF-PHC guidelines more primary-care physicians reported that they recommend CRC screening to their average-risk patients. The belief that the evidence is inconclusive nevertheless remains a considerable barrier to implementation. To increase the use of screening for CRC, additional strategies are required.

CARD15 and HLA DRB1 alleles influence susceptibility and disease localization in Crohn's disease

OBJECTIVES

Crohn's disease (CD) is a chronic inflammatory disease of the gut associated with allelic variants of CARD15 and HLA-DRB1 genes. We investigated the prevalence and effects of these variants in a Canadian CD cohort.

METHODS

507 unrelated CD patients were genotyped for the three major CD-associated variants (Arg702Trp, Gly908Arg, and Leu1007fsinsC) and for thirteen HLA-DRB1 alleles.

RESULTS

At least one CARD15 variant was present in 32.5% of the CD patients compared with 20% of controls. The prevalence of CARD15 mutation was similar in both sporadic and familial and Jewish and non-Jewish CD patients. The Gly908Arg variant was significantly higher and the Arg702Trp variant significantly lower in Jewish compared to non-Jewish patients. A positive association between the HLA-DRB1*0103 allele and CD was detected in non-Jewish, familial cases (p = 0.0002), with risk for CD increased by 6.7 fold by the presence of an HLA-DRB1*0103 allele as compared to 1.9 fold and 19 fold by a single or two CARD15 variant alleles, respectively. We show a significant association of ileal involvement with CARD15 variants (OR = 1.8; p = 0.02), HLA-DRB1*0701 (OR = 1.9; p = 0.006) and DRB1*04 (OR = 1.7; p = 0.02) alleles and demonstrate the capacity of combined CARD15 and HLA-DRB1 genotyping to predict ileal disease in CD patients. By contrast, the HLA-DRB1*0103 allele was associated with later age of diagnosis (p = 0.02) and pure colonic disease (p = 0.000013).

CONCLUSIONS

These observations confirm the influence of CARD15 and HLA-DRB1 alleles on both CD susceptibility and site of disease and identify genotyping of these variants as a potential tool for improved diagnosis and risk prediction in CD.

Non steroidal anti-inflammatory drugs (NSAID) and Aspirin for preventing colorectal adenomas and carcinomas

EDITORIAL NOTE

This review was split in 2012 and the review question was to be addressed according to three new protocols: (See: http://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010267.pub2; http://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010291.pub2; http://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010325.pub2). These titles were withdrawn at the protocol stage in 2020 as the authors did not make any progress on the reviews. This original review will no longer be updated and may be superseded by new titles hosted by Cochrane Gut in the future.

BACKGROUND

There is evidence from experimental animals studies, prospective and retrospective observational studies that nonsteroidal anti-inflammatory drugs (NSAIDS) may reduce the development of sporadic colorectal adenomas (CRAs) and cancer (CRC) and may induce the regression of adenomas in familial adenomatous polyposis (FAP).

OBJECTIVES

To conduct a systematic review to determine the effect of NSAIDS for the prevention or regression of CRAs and CRC.

SEARCH STRATEGY

Randomized controlled trials (RCTs) up to September 2003 were identified.

SELECTION CRITERIA

NSAIDS and aspirin (ASA) were the interventions. The primary outcomes were the number of subjects with at least one CRA, the change in polyp burden, and CRC. The secondary outcome was adverse events.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality. Dichotomous outcomes were reported as relative risks (RR) with 95% confidence intervals (CI). The data were combined with the random effects model if clinically and statistically reasonable.

MAIN RESULTS

Nine trials with 150 familial adenomatous polyposis (FAP) and 24,143 population subjects met the inclusion criteria. The interventions included sulindac, celecoxib, or aspirin (ASA). From the combined results of three trials, significantly fewer subjects in the low dose ASA group developed recurrent sporadic CRAs [RR 0.77 (95% CI 0.61, 0.96), (NNT 12.5 (95% CI 7.7, 25)] after one to three years. In another three trials, phenotypic FAP subjects that received sulindac or celecoxib had a greater proportional reduction (range: 11.9% to 44%) in the number of CRAs compared to those in the control group (range: 4.5% to 10%). There was no significant difference for the outcomes of CRC or adverse events in any of the trials.

REVIEWERS' CONCLUSIONS

There was evidence from three pooled RCTs that ASA significantly reduces the recurrence of sporadic adenomatous polyps after one to three years. There is evidence from short-term studies to support regression, but not elimination or prevention of CRAs in FAP.

Assessment of critical appraisal skills

BACKGROUND

Studies have provided little evidence that critical appraisal skills improve with focused courses. However, outcome measures in these studies have been questionable. The goal of this study was to develop a feasible, reliable, and valid assessment of critical appraisal skills.

METHODS

Forty-four surgery residents read three articles and then responded to short answer questions and provided 7-point ratings regarding various methodological aspects of each article. Reliability and validity of the examination were assessed.

RESULTS

The mean score was 52.4% (SD 8.6%). Internal consistency of the 55-question examination was 0.77. Interrater reliability of clinician markers was 0.91. Mean score for residents with more intensive critical appraisal training was significantly higher than for those with little or no training (56.6% versus 49.3%, t(35) = 2.31, P = 0.02), suggesting construct validity.

CONCLUSIONS

This examination has promising psychometric properties, and may be useful in evaluating critical appraisal curricula.

Outcome of patients undergoing liver transplantation for primary sclerosing cholangitis

PURPOSE

The purpose of this study was to determine the outcome of patients with inflammatory bowel disease who underwent liver transplantation for primary sclerosing cholangitis.

METHODS

All patients who underwent liver transplantation for primary sclerosing cholangitis at our institution were identified. A review of patients' hospital and office charts was performed; all patients were then contacted, and a detailed survey was administered by telephone.

RESULTS

Sixty-nine patients were identified. There were 53 males (76.8 percent) and 16 females, with a mean age of 45.3 (+/- 13.3) years. Fifty-two (75.4 percent) of the 69 patients had documented inflammatory bowel disease; of these, 40 had ulcerative colitis (76.9 percent), 11 had Crohn's disease, and 1 had indeterminate colitis. Thirty-one patients (60 percent) were diagnosed with inflammatory bowel disease before primary sclerosing cholangitis, with a mean interval to diagnosis of primary sclerosing cholangitis of 10.8 (+/- 10.3) years. Seven patients had both diagnoses made at roughly the same time, and 14 patients initially were diagnosed with primary sclerosing cholangitis and subsequently were found to have inflammatory bowel disease, with a mean interval of 5.2 (+/- 4.4) years; 5 (35.7 percent) of those 14 patients were only diagnosed with inflammatory bowel disease after their liver transplant. The mean time from diagnosis of primary sclerosing cholangitis to liver transplantation was 6.1 (+/- 4.9) years. Since their transplant, 30.8 percent of patients rated their colitis as worse, 38.5 percent felt it was unchanged, and 30.8 percent felt that their colitis was better controlled. Eight (15.4 percent) of the 52 patients with inflammatory bowel disease denied having any knowledge of an increased risk of colorectal neoplasia. Four patients have required colectomy for colorectal neoplasia after liver transplantation, at a mean of 4.7 years after transplantation. Of the patients with inflammatory bowel disease, 42 (80.1 percent) had at least 1 posttransplant surveillance colonoscopy. Eight of the remaining ten patients had a colectomy, leaving only two patients (3.8 percent) who had not been surveyed. However, only 32 (61.5 percent) of the patients with inflammatory bowel disease have been on a surveillance regimen that would approximately conform to current screening recommendations.

CONCLUSIONS

The activity of inflammatory bowel disease after transplantation is highly variable. Patients appeared to lack knowledge of their increased risk for colorectal neoplasia. Colorectal cancer is an uncommon but important complication in patients after liver transplantation for primary sclerosing cholangitis, and ongoing surveillance is required. Patients may require education to increase their awareness of the cancer risk and compliance with surveillance.

Epidemiologic features of acute appendicitis in Ontario, Canada

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.

Home total parenteral nutrition: an alternative to early surgery for complicated inflammatory bowel disease

This paper examines the safety and feasibility of providing short-term, in-home total parenteral nutrition (TPN) for patients with inflammatory bowel disease (IBD) for whom the alternative is prolonged hospitalization or early surgery. The records of all patients with IBD who were receiving temporary home TPN between June 1996 and July 2000 were reviewed. A quality-of-life phone interview was conducted at the time of review. Fifteen patients (11 men and 4 women) were identified whose average age was 35 years. The underlying diagnosis was Crohn's disease in 10 and ulcerative colitis in five. The indications for home TPN were complex internal fistulas and resolving sepsis in two, postoperative septic complications (anastomotic leak/enterocutaneous fistula) in five, high-output proximal stomas in four, prolonged ileus/partial obstruction in three, and spontaneous enterocutaneous fistula in one. The average duration of home TPN was 75 days (range 7 to 240 days). Two patients (13%) failed home TPN (1 with uncontrolled sepsis; 1 with dehydration) and were readmitted to the hospital. Home TPN was discontinued in one patient whose enterocutaneous fistula failed to heal with nonoperative treatment. Home TPN was successful in 12 patients (80%): eight (53%) who underwent planned definitive surgery and four (27%) whose conditions resolved without surgery. Complications of home TPN were line sepsis and pulmonary aspergillosis in one patient. All patients preferred home TPN to further hospitalization and reported good or excellent quality of life at home. Home TPN is a safe alternative to prolonged hospitalization or early surgery in patients with complicated IBD.