Validation of body surface colonic mapping (BSCM) against high resolution colonic manometry for evaluation of colonic motility

Abnormal cyclic motor pattern (CMP) activity is implicated in colonic dysfunction, but the only tool to evaluate CMP activity, high-resolution colonic manometry (HRCM), remains expensive and not widely accessible. This study aimed to validate body surface colonic mapping (BSCM) through direct correlation with HRCM. Synchronous meal-test recordings were performed in asymptomatic participants with intact colons. A signal processing method for BSCM was developed to detect CMPs. Quantitative temporal analysis was performed comparing the meal responses and motility indices (MI). Spatial heat maps were also compared. Post-study questionnaires evaluated participants' preference and comfort/distress experienced from either test. 11 participants were recruited and 7 had successful synchronous recordings (5 females/2 males; median age: 50 years [range 38-63]). The best-correlating MI temporal analyses achieved a high degree of agreement (median Pearson correlation coefficient (Rp) value: 0.69; range 0.47-0.77). HRCM and BSCM meal response start and end times (Rp = 0.998 and 0.83; both p < 0.05) and durations (Rp = 0.85; p = 0.03) were similar. Heat maps demonstrated good spatial agreement. BSCM is the first non-invasive method to be validated by demonstrating a direct spatio-temporal correlation to manometry in evaluating colonic motility.

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

BACKGROUND

Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks.

METHODS

The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned.

RESULTS

A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31).

CONCLUSION

Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov).

Interval colorectal cancers after negative faecal immunochemical test in the New Zealand Bowel Screening Pilot

OBJECTIVE

Evaluate the diagnostic performance of faecal immunochemical test (FIT), identify risk factors for FIT-interval colorectal cancers (FIT-IC) and describe long-term outcomes of participants with colorectal cancers (CRC) in the New Zealand Bowel Screening Pilot (BSP).

DESIGN

From 2012 to 2017, the BSP offered eligible individuals, aged 50-74 years, biennial screening using a quantitative FIT with positivity threshold of 15 µg haemoglobin (Hb)/g faeces. Retrospective review of prospectively maintained data extracted from the BSP Register and New Zealand Cancer Registry identified any CRC reported in participants who returned a definitive FIT result. Further details were obtained from hospital records. FIT-ICs were primary CRC diagnosed within 24 months of a negative FIT. Factors associated with FIT-ICs were identified using logistic regression.

RESULTS

Of 387 215 individuals invited, 57.4% participated with 6.1% returning positive FIT results. Final analysis included 520 CRC, of which 111 (21.3%) met FIT-IC definition. Overall FIT sensitivity for CRC was 78.7% (95% CI=74.9% to 82.1%), specificity was 94.1% (95% CI=94.0% to 94.2%). In 78 (70.3%) participants with FIT-IC, faecal Hb was reported as undetectable. There were no significant associations between FIT-IC and age, sex, ethnicity and deprivation. FIT-ICs were significantly associated with proximal tumour location, late stage at diagnosis, high-grade tumour differentiation and subsequent round screens. Median follow-up time was 74 (2-124) months. FIT-IC had significantly poorer overall survival.

CONCLUSION

FIT sensitivity in BSP compared favourably to published data. FIT-ICs were more likely to be proximal tumours with poor long-term outcomes. Further lowering of FIT threshold would have minimal impact on FIT-IC.

Risk factors for readmission in patients with acute diverticulitis: a retrospective study at Auckland City Hospital

AIM

Approximately one in five patients with acute diverticulitis (AD) will experience a recurrence. This study aimed to investigate the factors at AD admission that correlate with recurrence and test the proposed risk of recurrence-score according to Sallinen et al. method: This retrospective study followed patients for five years who were admitted with operatively or computed tomography (CT)-verified AD at Auckland City Hospital from January 2012-June 2013. Demographic, laboratory, radiological and patient-related factors at initial admission were analysed in relation to readmission with recurrent AD and to test a risk score presented by Sallinen et al. results: In the adjusted analyses, previous diagnosis of AD (OR, 7.3; 95% CI, 3.1-16.9), Māori ethnicity (OR, 5.7; 95% CI, 1.4-22.7) and complicated AD at index admission (OR, 2.5; 95% CI, 1.0-6.2), were all independent factors associated with readmission with recurrence. High-risk versus low-risk groups, according to the risk score, showed 71.4% and 18.6% recurrence rates, respectively.

CONCLUSION

History of diverticulitis and complicated AD are risk factors for recurrence. The finding of higher recurrence rate in Māori requires further investigation utilising appropriate research methodologies. The risk score presented by Sallinen et al. may be a useful predictor of recurrent AD.

Meta-Analysis of the Composition of Human Intestinal Gases

BACKGROUND

Understanding intestinal gases volume and composition may contribute to diagnosing digestive diseases and the microbiome's status. This meta-analysis aimed to define the composition of human intestinal gases and changes associated with diet.

METHODS

Studies were identified by systematic research of the MEDLINE(Ovid), Scopus, and Cochrane databases. Studies that measured the concentration of intestinal gases in healthy adult humans were retrieved. The JBI critical appraisal tool was used to evaluate the risk of bias. The primary outcomes analysed were the concentration of the most prevalent colonic gases. Participants were divided into groups according to dietary fibre content.

RESULTS

Eleven studies were included. The following gases were identified in similar concentrations across all studies (mean ± standard deviation): nitrogen (65.1 ± 20.89%), oxygen (2.3 ± 0.98%), carbon dioxide (9.9 ± 1.6%), hydrogen (2.9 ± 0.7%), and methane (14.4 ± 3.7%). Differences according to the dietary fibre were observed, with a positive correlation between fibre and volume of gas produced, particularly in fermented gases (carbon dioxide, hydrogen, and methane).

DISCUSSION

The meta-analysis has found defined concentrations of the five most common gases present in human colonic gas. Limitations included heterogenic methodologies, a low number of participants, and few recent studies. These findings may be helpful in diagnostic applications where colonic gas volume and composition are crucial factors, including functional disorders, microbiome analyses, and bowel perforation diagnostics.

Effect of prucalopride to improve time to gut function recovery following elective colorectal surgery: randomized clinical trial

BACKGROUND

Delayed return to gut function and prolonged postoperative ileus (PPOI) delay recovery after colorectal surgery. Prucalopride is a selective serotonin-4-receptor agonist that may improve gut motility.

METHODS

This was a multicentre, double-blind, parallel, placebo-controlled randomized trial of 2 mg prucalopride versus placebo in patients undergoing elective colorectal resection. Patients with inflammatory bowel disease and planned ileostomy formation were excluded, but colostomy formation was allowed. The study medication was given 2 h before surgery and daily for up to 6 days after operation. The aim was to determine whether prucalopride improved return of gut function and reduced the incidence of PPOI. The primary endpoint was time to passage of stool and tolerance of diet (GI-2). Participants were allocated in a 1 : 1 ratio, in blocks of 10. Randomization was computer-generated. All study personnel, medical staff, and patients were blinded.

RESULTS

This study was completed between October 2017 and May 2020 at two tertiary hospitals in New Zealand. A total of 148 patients were randomized, 74 per arm. Demographic data were similar in the two groups. There was no difference in median time to GI-2 between prucalopride and placebo groups: 3.5 (i.q.r. 2-5) versus 4 (3-5) days respectively (P = 0.124). Prucalopride improved the median time to passage of stool (3 versus 4 days; P = 0.027) but not time to tolerance of diet (2 versus 2 days; P = 0.669) or median duration of hospital stay (4 versus 4 days; P = 0.929). In patients who underwent laparoscopic surgery (125, 84.5 per cent), prucalopride improved median time to GI-2: 3 (2-4) days versus 4 (3-5) days for placebo (P = 0.012). The rate of PPOI, complications, and adverse events was similar in the two groups.

CONCLUSION

Prucalopride did not improve time to overall recovery of gut function after elective colorectal surgery. Registration number: NCT02947269 (http://www.clinicaltrials.gov).

Evaluation of the inflammatory profile following uncomplicated elective colectomy

Background

Attenuation of the inflammatory response in patients undergoing colectomy with modern perioperative care and laparoscopic surgery has been a focus of research in recent years. Despite reported benefits, significant heterogeneity remains with studies including patients undergoing both rectal and colon surgery and including surgery with postoperative complications. Therefore, the aim of the study was to evaluate the inflammatory response in patients undergoing elective colectomy without complications, specifically comparing open and laparoscopic approaches.

Methods

A multicenter prospective study was conducted across four public hospitals in Auckland and Christchurch, New Zealand. Consecutive adults undergoing elective colectomy were included over a 3‐year period. Perioperative blood samples were collected and analysed for the following inflammatory markers: IL‐6, IL‐1β, TNFα, IL‐10, CRP, leucocyte and neutrophil count. Statistical analysis was performed using SPSS statistical software.

Results

A total of 168 colectomy patients without complications were included in the analysis. Patients that underwent laparoscopy had significantly reduced IL‐6, neutrophils and CRP on postoperative day (POD) 1 (p < 0.05) compared to an open approach. IL‐10 and TNFα were significantly reduced on POD 2 (p < 0.05) in laparoscopic patients. Patients with a Body Mass Index (BMI) greater than 30 kg/m² had significantly higher levels of CRP regardless of operative approach. Statins altered both preoperative and postoperative inflammatory markers.

Conclusion

The postoperative inflammatory response is influenced by surgical approach, perioperative medications, and patient factors. These findings have important implications in the utility of biomarkers in the diagnosis of postoperative surgical complications, in particular in the early diagnosis of anastomotic leak.

Faecal immunochemical test to triage patients with possible colorectal cancer symptoms: meta-analysis

BACKGROUND

This review evaluated the utility of single quantitative faecal immunochemical test (FIT) as a triaging tool for patients with symptoms of possible colorectal cancer, the effect of symptoms on FIT accuracy, and the impact of triaging incorporating FIT on service provision.

METHODS

Five databases were searched. Meta-analyses of the extracted FIT sensitivities and specificities for detection of colorectal cancer at reported f-Hb thresholds were performed. Secondary outcomes included sensitivity and specificity of FIT for advanced colorectal neoplasia and serious bowel disease. Subgroup analysis by FIT brand and symptoms was undertaken.

RESULTS

Fifteen prospective cohort studies, including 28 832 symptomatic patients were included. At the most commonly reported f-Hb positivity threshold of ≥ 10 µg Hb/g faeces (n=13), the summary sensitivity was 88.7% (95% c.i. 85.2 to 91.4) and the specificity was 80.5% (95% c.i. 75.3 to 84.8) for colorectal cancer. At lower limits of detection of ≥ 2 µg Hb/g faeces, the summary sensitivity was 96.8% (95% c.i. 91.0 to 98.9) and the specificity was 65.6% (95% c.i. 59.0 to 71.6). At the upper f-Hb positivity thresholds of ≥ 100 µg Hb/g faeces and ≥ 150 µg Hb/g faeces, summary sensitivities were 68.1% (95% c.i. 59.2 to 75.9) and 66.3% (95% c.i. 52.2 to 78.0), with specificities of 93.4% (95% c.i. 91.3 to 95.1) and 95.1% (95% c.i. 93.6 to 96.3) respectively. FIT sensitivity was comparable between different assay brands. FIT sensitivity may be higher in patients reporting rectal bleeding.

CONCLUSION

Single quantitative FIT at lower f-Hb positivity thresholds can adequately exclude colorectal cancer in symptomatic patients and provides a data-based approach to prioritization of colonoscopy resources.

The intensivist's assessment of gastrointestinal function: A pilot study

Gastrointestinal dysfunction/failure (GDF) is a common cause of concern in critically ill patients. Although the gut plays an important role in the genesis of organ failure, its exclusion from organ severity scoring systems has made it challenging for intensivists to score it sufficiently at the bedside. We aimed to survey intensive care specialists about their perceptions, attitudes, and approaches towards the assessment of the gut in Australia and New Zealand intensive care units (ICUs). An electronic (online) questionnaire was used to survey intensive care specialists from the Australia and New Zealand Intensive Care Society (ANZICS). The survey comprised 10 questions focused on four key areas: (i) the extent of the problem with GDF in ICUs, (ii) the use and reliability of the current gut scoring tools, (iii) personal approaches and practices associated with GDF assessment, and (4) potential value of a novel GDF scoring system and its incorporation into an organ severity score. Our results showed that GDF was a significant concern amongst ICUs in Australia and New Zealand intensivists (84%; 66/79), with a small number of participants (14%; 3/79) using a gut scoring tool in their ICUs. Despite this, we have no established objective scoring tool for its assessment. The survey highlighted the need for developing a novel scoring tool to assess the gut was considered important amongst majority of the intensivists (92%; 72/78), which would prove useful in clinical practice and potentially lead to incorporation into an organ severity score in the future.

Review article: Has the implementation of time-based targets for emergency department length of stay influenced the quality of care for patients? A systematic review of quantitative literature

Time-based targets (TBTs) for ED stays were introduced to improve quality of care but criticised as having harmful unintended consequences. The aim of the review was to determine whether implementation of TBTs influenced quality of care. Structured searches in medical databases were undertaken (2000-2019). Studies describing a state, regional or national TBTs that reported processes or outcomes of care related to the target were included. Harvest plots were used to summarise the evidence. Thirty-three studies (n = 34 million) were included. In some settings, reductions in mortality were seen in ED, in hospital and at 30 days, while in other settings mortality was unchanged. Mortality reductions were seen in the face of increasing age and acuity of presentations, when short-stay admissions were excluded, and when pre-target temporal trends were accounted for. ED crowding, time to assessment and admission times reduced. Fewer patients left prior to completing their care and fewer patients re-presented to EDs. Short-stay admissions and re-admissions to wards within 30 days increased. There was conflicting evidence regarding hospital occupancy and ward medical emergency calls, while times to treatment for individual conditions did not change. The evidence for associations was mostly low certainty and confidence in the findings is accordingly low. Quality of care generally improved after targets were introduced and when compliance with targets was high. This depended on how targets were implemented at individual sites or within jurisdictions, with important implications for policy makers, health managers and clinicians.

Risk factors for readmission with dehydration after ileostomy formation: A systematic review and meta-analysis

AIM

Ileostomy formation is a commonly performed procedure with substantial associated morbidity. Patients with an ileostomy experience high rates of unplanned hospital readmission with dehydration, and such events have a long-term health and economic impact. Reports of the significant risk factors associated with these readmissions have been inconsistent. This study aimed to identify the significant risk factors for readmission with dehydration following ileostomy formation.

METHOD

A systematic search was conducted using the Medline, Embase, Cochrane and CINAHL databases. All original research articles reporting risk factors for readmission with dehydration following ileostomy formation in adults were included. The primary outcome was the pooled risk ratio of clinically relevant variables potentially associated with dehydration-related readmission following ileostomy formation. The secondary outcome was the incidence of dehydration-related readmission.

RESULTS

Ten studies (27 089 patients) were included. The incidences of 30- and 60-day readmission with dehydration were 5.0% (range 2.1%-13.2%) and 10.3% (range 7.3%-14.1%), respectively. Eight variables were found to be significantly associated with dehydration-related readmission: age ≥65 years, body mass index ≥30 kg/m² , diabetes mellitus, hypertension, renal comorbidity, regular diuretic use, ileal pouch-anal anastomosis procedure and length of stay after index admission. A preoperative diagnosis of colorectal cancer was less likely to result in readmission with dehydration.

CONCLUSION

Readmission with dehydration following ileostomy formation is a significant issue with several risk factors. Awareness of these risk factors will help inform the design of future studies addressing risk prediction, allow risk stratification of ileostomates and aid in the development of personalized prevention strategies.

Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial

BACKGROUND & AIMS

Antibiotic treatment is the standard care for patients with uncomplicated acute diverticulitis. However, this practice is based on low-level evidence and has been challenged by findings from 2 randomized trials, which did not include a placebo group. We investigated the non-inferiority of placebo vs antibiotic treatment for the management of uncomplicated acute diverticulitis.

METHODS

In the selective treatment with antibiotics for non-complicated diverticulitis study, 180 patients hospitalized for uncomplicated acute diverticulitis (determined by computed tomography, Hinchey 1a grade) from New Zealand and Australia were randomly assigned to groups given antibiotics (n = 85) or placebo (n = 95) for 7 days. We collected demographic, clinical, and laboratory data and answers to questionnaires completed every 12 hrs for the first 48 hrs and then daily until hospital discharge. The primary endpoint was length of hospital stay; secondary endpoints included occurrence of adverse events, readmission to the hospital, procedural intervention, change in serum markers of inflammation, and patient-reported pain scores at 12 and 24 hrs.

RESULTS

There was no significant difference in median time of hospital stay between the antibiotic group (40.0 hrs; 95% CI, 24.4-57.6 hrs) and the placebo group (45.8 hrs; 95% CI, 26.5-60.2 hrs) (P = .2). There were no significant differences between groups in adverse events (12% for both groups; P = 1.0), readmission to the hospital within 1 week (1% for the placebo group vs 6% for the antibiotic group; P = .1), and readmission to the hospital within 30 days (11% for the placebo group vs 6% for the antibiotic group; P = .3).

CONCLUSIONS

Foregoing antibiotic treatment did not prolong length of hospital admission. This result provides strong evidence for omission of antibiotics for selected patients with uncomplicated acute diverticulitis.

ACTRN

12615000249550.

Review article: Have emergency department time-based targets influenced patient care? A systematic review of qualitative literature

Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.

Variable Gut Function Recovery After Right vs. Left Colectomy May Be Due to Rectosigmoid Hyperactivity

It is established that gut function recovers slower after right vs. left colectomies with higher rates of prolonged post-operative ileus (PPOI), but the reason is unclear. Development of PPOI is multifactorial. A recent manometry study in right colectomy patients showed that the distal colon becomes hyperactive after surgery with predominantly cyclic motor patterns (CMPs). In this perspective, we evaluate the hypothesis that the slower gut recovery after right hemicolectomy could be induced by a functional obstruction due to hyperactive CMPs.

Altered colonic motility is associated with low anterior resection syndrome

AIM

Patients frequently suffer from low anterior resection syndrome (LARS) after distal colorectal resection. The pathophysiology of LARS has not been clearly elucidated. We hypothesized that rectosigmoid resection could impair motility patterns in the distal colon, such as the rectosigmoid brake, which contribute to control of stool form and frequency.

METHOD

High-resolution colonic manometry was performed in patients who had previously undergone distal colorectal resection (mean 6.8 years after resection) and non-operative controls before and after a standardized meal. Symptoms were assessed using the LARS score. Propagating contractions were compared between patients with and without LARS, and controls.

RESULTS

Data were analysed from 23 patients (11 no-LARS; 12 LARS) and nine controls. All groups demonstrated a significant meal response. LARS patients had fewer post-prandial antegrade propagating contractions than controls (P = 0.028), and fewer retrograde propagating contractions both pre- (P = 0.005) and post-prandially (P = 0.004). Post-prandially, the LARS group had a significantly lower percentage of propagating contractions that met the criteria for the cyclic motor pattern compared to the control group (26% vs. 58%; P = 0.009). There were significant differences in antegrade and retrograde amplitude (P = 0.049; P = 0.018) and distance of propagation (P = 0.003; P = 0.002) post-prandially between LARS patients and controls.

CONCLUSION

Rectosigmoid resection alters the meal response following anterior resection, including impairment of the rectosigmoid brake cyclic motor pattern. These findings help to quantify the impaired functional motility after rectosigmoid resection and offer new insights into the mechanisms of LARS.

ManoMap: an automated system for characterization of colonic propagating contractions recorded by high-resolution manometry

RATIONALE

Colonic high-resolution manometry (cHRM) is an emerging clinical tool for defining colonic function in health and disease. Current analysis methods are conducted manually, thus being inefficient and open to interpretation bias.

OBJECTIVE

The main objective of the study was to build an automated system to identify propagating contractions and compare the performance to manual marking analysis.

METHODS

cHRM recordings were performed on 5 healthy subjects, 3 subjects with diarrhea-predominant irritable bowel syndrome, and 3 subjects with slow transit constipation. Two experts manually identified propagating contractions, from five randomly selected 10-min segments from each of the 11 subjects (72 channels per dataset, total duration 550 min). An automated signal processing and detection platform was developed to compare its effectiveness to manually identified propagating contractions. In the algorithm, individual pressure events over a threshold were identified and were then grouped into a propagating contraction. The detection platform allowed user-selectable thresholds, and a range of pressure thresholds was evaluated (2 to 20 mmHg).

KEY RESULTS

The automated system was found to be reliable and accurate for analyzing cHRM with a threshold of 15 mmHg, resulting in a positive predictive value of 75%. For 5-h cHRM recordings, the automated method takes 22 ± 2 s for analysis, while manual identification would take many hours.

CONCLUSIONS

An automated framework was developed to filter, detect, quantify, and visualize propagating contractions in cHRM recordings in an efficient manner that is reliable and consistent.

The impact of transanal tube design for preventing anastomotic leak in anterior resection: a systematic review and meta-analysis

BACKGROUND

Placement of a transanal tube (TAT) into the rectum is a strategy used to attempt to prevent anastomotic leak (AL) in anterior resection surgery. There is a wide variation in materials and tube design in devices used as TATs and previous meta-analyses have not considered TAT design in their analyses. This study reviews the impact that design of TAT has on AL rates.

METHODS

A systematic review of the literature was performed with the aim of identifying studies evaluating the use of TATs for preventing AL and then defining the design of TATs. Studies were then compared in groups based on TAT design in a meta-analysis to evaluate whether design is an important variable in outcomes.

RESULTS

Thirty-three studies were included. There was a wide variety of tubes used as TATs. On meta-analysis, catheter-type TATs were associated with a substantially lower rate of AL (OR: 0.46; 95% CI 0.30, 0.68). By contrast, stent-type TATs were not associated with any reduction in the incidence of AL (OR: 1.06, 95% CI 0.50, 2.22). Catheter-type TATs were also associated with substantial reductions in the rate of reoperation (OR: 0.32; 95% CI 0.20, 0.50), whereas stent-type TATs showed no benefit in the rate of reoperation (OR: 0.79; 95% CI 0.37, 1.65).

CONCLUSIONS

Off-the-shelf catheter-type transanal tubes appeared effective in preventing AL, whereas custom-designed stent-type TATs were not demonstrated to be effective; although high quality evidence is limited. TAT design should be an important consideration in further research of the use of TATs in anterior resection surgery.

Prospective validation of classification of intraoperative adverse events (ClassIntra): international, multicentre cohort study

OBJECTIVE

To prospectively assess the construct and criterion validity of ClassIntra version 1.0, a newly developed classification for assessing intraoperative adverse events.

DESIGN

International, multicentre cohort study.

SETTING

18 secondary and tertiary centres from 12 countries in Europe, Oceania, and North America.

PARTICIPANTS

The cohort study included a representative sample of 2520 patients in hospital having any type of surgery, followed up until discharge. A follow-up to assess mortality at 30 days was performed in 2372 patients (94%). A survey was sent to a representative sample of 163 surgeons and anaesthetists from participating centres.

MAIN OUTCOME MEASURES

Intraoperative complications were assessed according to ClassIntra. Postoperative complications were assessed daily until discharge from hospital with the Clavien-Dindo classification. The primary endpoint was construct validity by investigating the risk adjusted association between the most severe intraoperative and postoperative complications, measured in a multivariable hierarchical proportional odds model. For criterion validity, inter-rater reliability was evaluated in a survey of 10 fictitious case scenarios describing intraoperative complications.

RESULTS

Of 2520 patients enrolled, 610 (24%) experienced at least one intraoperative adverse event and 838 (33%) at least one postoperative complication. Multivariable analysis showed a gradual increase in risk for a more severe postoperative complication with increasing grade of ClassIntra: ClassIntra grade I versus grade 0, odds ratio 0.99 (95% confidence interval 0.69 to 1.42); grade II versus grade 0, 1.39 (0.97 to 2.00); grade III versus grade 0, 2.62 (1.31 to 5.26); and grade IV versus grade 0, 3.81 (1.19 to 12.2). ClassIntra showed high criterion validity with an intraclass correlation coefficient of 0.76 (95% confidence interval 0.59 to 0.91) in the survey (response rate 83%).

CONCLUSIONS

ClassIntra is the first prospectively validated classification for assessing intraoperative adverse events in a standardised way, linking them to postoperative complications with the well established Clavien-Dindo classification. ClassIntra can be incorporated into routine practice in perioperative surgical safety checklists, or used as a monitoring and outcome reporting tool for different surgical disciplines. Future studies should investigate whether the tool is useful to stratify patients to the appropriate postoperative care, to enhance the quality of surgical interventions, and to improve long term outcomes of surgical patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03009929.

Re-admissions after ileostomy formation: a retrospective analysis from a New Zealand tertiary centre

BACKGROUND

Ileostomy formation is a commonly performed procedure in colorectal surgery. The morbidity associated with ileostomies is substantial, particularly for unplanned hospital re-admissions and re-admissions with dehydration. Studies of post-ileostomy re-admissions from an Australasian institution are currently lacking. This retrospective study aimed to quantify the 60-day re-admission rate after ileostomy formation in a New Zealand tertiary centre and to determine the predictive factors.

METHODS

The surgical database of Auckland City Hospital was searched for all patients aged ≥18 years with a new ileostomy formed between first January 2015 and first January 2019. Patient electronic medical records were reviewed to obtain data regarding the primary outcome of re-admissions within 60 days of discharge, as well as patient and operative variables. Multivariate regression analysis was performed to identify independent predictors of all-cause re-admissions and re-admissions with dehydration.

RESULTS

A total of 246 patients with 266 ileostomy formations were included. The 60-day re-admission rate was 29.3%, with dehydration present in 27.0% of these re-admissions. Renal impairment at discharge (odds ratio 2.819, 95% confidence interval 1.087-7.310) and the presence of at least one Clavien-Dindo 1 complication (odds ratio 2.268, 95% confidence interval 1.301-3.954) were independently associated with all-cause re-admission. The independent predictors of re-admission with dehydration were renal impairment at discharge, codeine prescribed on discharge, Charlson Comorbidity Index and body mass index.

CONCLUSION

Unplanned hospital re-admission following ileostomy formation is a significant issue in the New Zealand patient population. Some patient groups are at particularly high risk, such as those with renal impairment at discharge.

A Novel High-Density Electromyography Probe for Evaluating Anorectal Neurophysiology: Design, Human Feasibility Study, and Validation with Trans-Sacral Magnetic Stimulation

Fecal incontinence (FI) substantially impairs quality of life and imparts a major socioeconomic burden. Anal sphincter injury and possibly pudendal nerve damage are considered common causes, however, current clinical methods for evaluating their function remain suboptimal. Electromyography (EMG) and pudendal nerve terminal latencies have been applied with some success, but are not considered standard practice due to uncertain accuracy and clinical value. In this study we developed and applied a novel anorectal high-density (HD) EMG probe in humans and pigs to acquire quantitative electrophysiological metrics of the anorectum. In the human trial we assessed somatic pathways and showed that EMG amplitude was greater for tight voluntary squeezes than light voluntary squeezes (0.03 ± 0.02 mV vs. 0.05 ± 0.03 mV). In a porcine model we applied trans-sacral magnetic stimulation to evoke extrinsically activated involuntary pathways and the resulting motor evoked potentials (MEP) were captured using the HD-EMG probe. The mean MEP amplitude at 50% magnetic stimulation intensity output (MSO) was significantly lower that the MEP amplitude at 85, 95 and 100% MSO (1.52 ± 0.50 mV vs. 3.10 ± 0.60 mV). In conclusion, the use of HD-EMG probe in conjunction with trans-sacral magnetic stimulation, for spatiotemporal mapping of anorectal EMG and MEP activity is anticipated to achieve new insights into FI and could offer improved diagnostic and prognostic biomarkers for anorectal dysfunction.

Comparison of bowel dysfunction between colorectal cancer survivors and a non-operative non-cancer control group

AIM

Low anterior resection syndrome (LARS) detrimentally affects quality of life in colorectal cancer survivors. This study assessed the prevalence for LARS in colorectal cancer survivors and the same symptoms in a matched control group.

METHOD

Validated instruments, the LARS score and Short Form Survey 12, used to collect functional and quality of life outcomes from patients who had undergone distal colorectal resection at Auckland Hospital (2008-2015) or Dunedin Hospital (2008-2017). A matched non-operative control group was drawn from patients undergoing surveillance colonoscopy.

RESULTS

The response rate was 79%. Cross-sectional prevalence of major LARS in rectal cancer patients was 52% at a median follow-up of 52 months. Major LARS prevalence in the sigmoid cancer resection and non-cancer control groups was similar (25% vs 26%, P = 0.6). On univariate analysis anastomotic height [risk ratio (RR) for low anterior resection 4.6, P < 0.001; ultralow anterior resection RR = 15.5, P < 0.001], radiotherapy (RR = 2.6; P = 0.009), stoma (RR = 3.6; P = 0.001) and J pouch reconstruction (vs straight anastomosis, RR = 4.6; P = 0.008) were associated with major LARS for rectal cancer patients. These factors were not significant when the analysis was stratified for anastomotic height. Despite correlation between LARS and Short Form Survey 12 outcomes (physical ρ = -0.2; mental ρ = -0.2) there was no difference in quality of life outcomes between the groups.

CONCLUSION

Bowel dysfunction after low anterior resection affects the majority of rectal cancer patients. The high background rate of bowel dysfunction must be considered when assessing the prevalence of LARS.

A Household Survey to Evaluate Access to Surgical Care in Vanuatu

INTRODUCTION

Surgical care is an integral part of any healthcare system, yet there is a paucity of data on the burden of surgical disease, surgical capacity and access to surgical services in the Pacific region. This study aimed to evaluate access to surgical care through a pilot household survey in the Vanuatu island of Efate and five of its surrounding islands.

METHODS

The 2009 Vanuatu census' GPS coordinates were used to randomly select 150 rural and 150 urban households from Efate and its surrounding islands. A total of 143 urban households and 142 rural households were available for inclusion in this study. A household questionnaire was developed to evaluate access to surgical care and included information regarding household demographics, socio-economic indicators and perceived and realised barriers to accessing care. The questionnaire was administered by local health workers, and data were collected electronically.

RESULTS

Questionnaires were completed by 285 households. Two hundred and forty-one out of 254 (94.8%) households reported being able to access Port Vila Hospital, if required. The most commonly cited potential barriers to accessing surgical care were financial constraints (42.4%) and transport (26.4%).

CONCLUSION

Our results provide important insights into the geographic, sociocultural and economic barriers to seeking, reaching and receiving surgical care in this region of Vanuatu. Identifying specific areas and communities with poor access to care, alongside the determinants of access, will help in designing both clinical and policy interventions to improve access to surgical care.

Manometry of the Human Ileum and Ileocaecal Junction in Health, Disease and Surgery: A Systematic Review

Background: The terminal ileum and ileocaecal junction form a transition zone in a relatively inaccessible portion of the gastrointestinal tract. Little is known about the motility of this region with few detailed studies, indicating the need for a robust synthesis of current knowledge. This review aimed to evaluate the quantitative and qualitative data on the manometry findings of the terminal ileum and ileocaecal junction during the fasting and post-prandial periods in healthy individuals and patients with motility disorders or patients after bowel surgery.

Methods: A systematic search of five databases (Medline, Pubmed, Embase, Scopus, and Cochrane Library) was performed. Studies that presented manometry data from the human ileum or ileocaecal junction were included.

Results: Forty-two studies met the inclusion criteria. The main motility patterns reported in the terminal ileum during fasting were the migrating motor complex, discrete clustered contractions, prolonged propagated contractions and phasic contractions. Post-prandial motility featured irregular, intense contractions. Some studies found a region of sustained increased pressure at the ileocaecal junction while others did not. Patients with motility disorders showed differences in manometry including retrograde propagation of phase III. Patients post-bowel surgery showed differences including higher incidence of phase III.

Conclusion: Motility patterns of the terminal ileum differ between fasting and fed states. Large variability existed in manometry recordings of the terminal ileum. Technical challenges and lack of standardized definitions may reduce accuracy of manometry assessment. Further research is needed to understand how this key portion of the gut physiologically functions.

International Consensus Definition of Low Anterior Resection Syndrome

BACKGROUND

Low anterior resection syndrome is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The low anterior resection syndrome score was designed as a simple tool for clinical evaluation of low anterior resection syndrome. Although the low anterior resection syndrome score has good clinical utility, it may not capture all important aspects that patients may experience.

OBJECTIVE

The aim of this collaboration was to develop an international consensus definition of low anterior resection syndrome that encompasses all aspects of the condition and is informed by all stakeholders.

DESIGN

This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting.

PARTICIPANTS

Three expert groups participated: patients, surgeons, and other health professionals from 5 regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in 3 languages (English, Spanish, and Danish).

MAIN OUTCOME MEASURE

The primary outcome measured was the priorities for the definition of low anterior resection syndrome.

RESULTS

Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96%, and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to 8 symptoms and 8 consequences that capture essential aspects of the syndrome.

LIMITATIONS

Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this.

CONCLUSIONS

This is the first definition of low anterior resection syndrome developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of low anterior resection syndrome. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in low anterior resection syndrome over time and with intervention.

International consensus definition of low anterior resection syndrome

AIM

Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders.

METHOD

This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS.

RESULTS

Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this.

CONCLUSION

This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

Impact of temporary ileostomy on long-term quality of life and bowel function: a systematic review and meta-analysis

BACKGROUND

Defunctioning ileostomy is widely used to protect a low colorectal anastomosis. However, the use of an ileostomy may have an impact on long-term bowel function and quality of life after anterior resection. The objectives were to compare bowel function and quality of life outcomes between patients undergoing an anterior resection for rectal cancer, with and without the formation of a diverting ileostomy, and to compare outcomes for early versus late closure of diverting ileostomy.

METHOD

A systematic literature review was performed to identify studies published between 2007 and 2018 comparing bowel function and quality of life outcomes after an anterior resection for rectal cancer in those with and without formation of a diverting ileostomy.

RESULTS

Four studies (three randomized controlled trials) reported bowel function and quality of life outcomes. Pooled analysis for 227 participants showed that having an ileostomy is associated with twice the risk of suffering from low anterior resection syndrome (odds ratio (major low anterior resection syndrome) 1.96, 95% confidence interval 1.1, 3.5; P = 0.02). There were no consistent differences in quality of life. Based on single studies there is limited evidence of some improvements in bowel function but no difference in quality of life after early compared to late closure of ileostomy.

CONCLUSION

There is some evidence for an association between low anterior resection syndrome and the use of a diverting ileostomy to protect a rectal anastomosis. Potential confounders include height of the anastomosis. Further research into the mechanisms underlying this potential association may inform methods to mitigate the harms of an ileostomy.

Surgical techniques in the management of rectal cancer: a modified Delphi method by colorectal surgeons in Australia and New Zealand

BACKGROUND

Technological developments have allowed advances in minimally invasive techniques for total mesorectal excision such as laparoscopy, robotics, and transanal surgery. There remains an ongoing debate about the safety, benefits, and appropriate clinical scenarios for which each technique is employed. The aim of this study was to provide a panel of expert opinion on the role of each surgical technique currently available in the management of rectal cancer using a modified Delphi method.

METHODS

Surveys were designed to explore the key patient- and tumor-related factors including clinical scenarios for determining a surgeon's choice of surgical technique.

RESULTS

Open surgery was favoured in obese patients with an extra-peritoneal tumor and a positive circumferential resection margin (CRM) or T4 tumor when a restorative resection was planned. Laparoscopy was favoured in non-obese males and females, in both intra- and extra-peritoneal tumors with a clear CRM. Robotic surgery was most commonly offered to obese patients when the CRM was clear and if an abdominoperineal resection was planned. Transanal total mesorectal excision (taTME) was preferred in male patients with a mid or low rectal cancer, particularly when obese. Transanal endoscopic microsurgery/transanal minimally invasive surgery local excision was only offered to frail patients with small, early stage tumors.

CONCLUSIONS

All surgical techniques for rectal cancer dissection have a role and may be considered appropriate. Some techniques have advantages over others in certain clinical situations, and the best outcomes may be achieved by considering all options before applying an individualised approach to each clinical situation.

The effect of implementing an aseptic practice bundle for anaesthetists to reduce postoperative infections, the Anaesthetists Be Cleaner (ABC) study: protocol for a stepped wedge, cluster randomised, multi-site trial

Background

Postoperative infection is a serious problem in New Zealand and internationally with considerable human and financial costs. Also, in New Zealand, certain factors that contribute to postoperative infection are more common in Māori and Pacific populations. To date, most efforts to reduce postoperative infection have focussed on surgical aspects of care and on antibiotic prophylaxis, but recent research shows that anaesthesia providers may also have an impact on infection transmission. These providers sometimes exhibit imperfect hand hygiene and frequently transfer the blood or saliva of their patients to their work environment. In addition, intravenous medications may become contaminated whilst being drawn up and administered to patients. Working with relevant practitioners and other experts, we have developed an evidence-informed bundle to improve key aseptic practices by anaesthetists with the aim of reducing postoperative infection. The key elements of the bundle are the filtering of compatible drugs, context-relevant hand hygiene practices and enhanced maintenance of clean work surfaces.

Methods

We will seek support for implementation of the bundle from senior anaesthesia and hospital leadership and departmental “champions”. Anaesthetic teams and recovery room staff will be educated about the bundle and its potential benefits through presentations, written material and illustrative videos. We will implement the bundle in operating rooms where hip or knee arthroplasty or cardiac surgery procedures are undertaken in a five-site, stepped wedge, cluster randomised, quality improvement design. We will compare outcomes between approximately 5000 cases before and 5000 cases after implementation of our bundle. Outcome data will be collected from existing national and hospital databases. Our primary outcome will be days alive and out of hospital to 90 days, which is expected to reflect all serious postoperative infections. Our secondary outcome will be the rate of surgical site infection. Aseptic practice will be observed in sampled cases in each cluster before and after implementation of the bundle.

Discussion

If effective, our bundle may offer a practical clinical intervention to reduce postoperative infection and its associated substantial human and financial costs.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12618000407291. Registered on 21 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3402-8) contains supplementary material, which is available to authorized users.

Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer

BACKGROUND

Low anterior resection syndrome (LARS) has a significant impact on postoperative quality of life. Although early closure of an ileostomy is safe in selected patients, functional outcomes have not been investigated. The aim was to compare bowel function and the prevalence of LARS in patients who underwent early or late closure of an ileostomy after rectal resection for cancer.

METHODS

Early closure (8-13 days) was compared with late closure (after 12 weeks) of the ileostomy following rectal cancer surgery in a multicentre RCT. Exclusion criteria were: signs of anastomotic leakage, diabetes mellitus, steroid treatment and postoperative complications. Bowel function was evaluated using the LARS score and the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI).

RESULTS

Following index surgery, 112 participants were randomized (55 early closure, 57 late closure). Bowel function was evaluated at a median of 49 months after stoma closure. Eighty-two of 93 eligible participants responded (12 had died and 7 had a permanent stoma). Rates of bowel dysfunction were higher in the late closure group, but this did not reach statistical significance (major LARS in 29 of 40 participants in late group and 25 of 42 in early group, P = 0·250; median BFI score 63 versus 71 respectively, P = 0·207). Participants in the late closure group had worse scores on the urgency/soiling subscale of the BFI (14 versus 17; P = 0·017). One participant in the early group and six in the late group had a permanent stoma (P = 0·054).

CONCLUSION

Patients undergoing early stoma closure had fewer problems with soiling and fewer had a permanent stoma, although reduced LARS was not demonstrated in this cohort. Dedicated prospective studies are required to evaluate definitively the association between temporary ileostomy, LARS and timing of closure.

Gastrografin may reduce time to oral diet in prolonged post-operative ileus: a pooled analysis of two randomized trials

BACKGROUND

Gastrografin has been suggested as a rescue therapy for prolonged post-operative ileus (PPOI) but trial data has been inconclusive. This study aimed to determine the benefit of gastrografin use in patients with PPOI by pooling the results of two recent randomized controlled trials assessing the efficacy of gastrografin compared to placebo given at time of PPOI diagnosis.

METHODS

Anonymized, individual patient data from patients undergoing elective bowel resection for any indication were included, stoma closure was excluded. The primary outcome was duration of PPOI. Secondary outcomes were time to tolerate oral diet, passage of flatus/stool, requirement and duration of nasogastric tube, length of post-operative stay and rate of post-operative complications.

RESULTS

Individual patient data were pooled for analysis (53 gastrografin, 55 placebo). Gastrografin trended towards a reduction in PPOI duration compared to placebo, respectively, median 96 h (interquartile range, IQR, 78 h) versus median 120 h (IQR, 84 h), however, this result was non-significant (P = 0.11). In addition, no significant difference was detected between the two groups for time to passage of flatus/stool (P = 0.36) and overall length of stay (P = 0.35). Gastrografin conferred a significantly faster time to tolerate an oral diet compared to placebo (median 84 h versus median 107 h, P = 0.04). There was no difference in post-operative complications between the two interventions (P > 0.05).

CONCLUSION

Gastrografin did not significantly reduce PPOI duration or length of stay after abdominal surgery, but did reduce time to tolerate a solid diet. Further studies are required to clarify the role of gastrografin in PPOI.

Screening for colorectal cancer: spoiled for choice?

There are many different potential screening strategies for colorectal cancer (CRC) that vary both in the likely magnitude of their benefits on CRC mortality and their impact on health services. Many approaches to CRC screening are cost-effective, but there is substantial uncertainty about the optimal approach. Decision models using Markov or microsimulation modelling that compare the cost-effectiveness of different screening strategies are useful in this regard. We have reviewed recent decision models that compare the cost-effectiveness of one-off flexible sigmoidoscopy screening with immunochemical faecal occult blood (FIT) based screening. Models consistently show that any population-based screening is cost-effective compared with no screening, and that FIT-based screening is more effective than one-off sigmoidoscopy screening. The combination of one-off sigmoidoscopy with FIT is more effective in saving lives than either modality alone, but has the greatest impact on health service resources. The recent decision to proceed with biennial FIT-based screening is consistent with current evidence.

Current management of acute diverticulitis: a survey of Australasian surgeons

AIMS

To evaluate the current practice and degree of consensus amongst Australasian surgeons regarding non-surgical management of acute diverticulitis (AD) and to determine whether newer approaches to management are being translated into practice.

METHODS

An online survey was distributed to all Australasian colorectal surgeons and all general surgeons in the Auckland region. Responses were collected over two months and analysed to identify points of consensus and areas of significant difference in opinion between these groups.

RESULTS

Responses were received from a total of 99 of 200 (49.5%) colorectal surgeons, and 19 of 36 (52.7%) general surgeons. The Hinchey Classification was the most commonly used measure of disease severity, used by 67 (95.7%) colorectal surgeons and 12 (92.3%) general surgeons. There was lack of consensus around important aspects of AD management, including antibiotic therapy, and use and modality of follow-up imaging. Selective antibiotic therapy and use of anti-inflammatory medication as adjuncts to treatment were practised by a minority of those surveyed.

CONCLUSIONS

Newer approaches to management were being utilised by some respondents. The lack of consensus regarding management of AD may be a consequence of a paucity of high-level evidence to support specific management approaches, particularly in patients with uncomplicated AD.

Early closure of temporary loop ileostomies: a systematic review

A temporary loop ileostomy is a common surgical procedure to protect colorectal anastomoses. The aim of this systematic review was to determine whether early closure of a defunctioning loop ileostomy (<2 weeks from index operation) is safe and reduces stoma-related morbidity. A systematic literature search was conducted using Ovid MEDLINE, EMBASE, Cochrane Collaboration, and the Cumulative Index to Nursing and Allied Health (CINAHL®) databases to identify all publications from January 1996 to March 2014 that reported the outcomes of early ileostomy closure. The following search terms (and their variations) were used as both medical subject headings (MeSH terms) and text words: ileostomy, surgical stoma, stoma, early, reversal, closure. No language restrictions were applied. The main outcomes of interest were stoma-related complications and postclosure complications. Studies that included pediatric patients (<18 years of age), small cohorts (<10 participants), case reports, conference abstracts, reviews, and letters; studies involving defunctioning colostomies or other types of small bowel stomas; and studies where results from closure of an ileostomy at >14 days could not be separated from early closure results were excluded. Where multiple studies were reported by the same institution and/or authors, only the most recent was included. This search strategy identified 4 studies (2 retrospective case series, 1 prospective nonrandomized study, and 1 randomized controlled trial), yielding a pooled population of 142 patients, ages 18-89 years old. Three studies reported indication for ileostomy; colorectal cancer accounted for 96 patients (78%). Time to ileostomy closure ranged from 8-14 days. No reported deaths were related to ileostomy closure. Wound infections were reported in 3 studies and were the most common complications, affecting 24 patients (19.8%). Of the 2 studies that reported ileostomy-related complications, 4 patients (3.6%) experienced a stoma-related complication before closure. Ileus or small bowel obstruction (SBO) occurred in 7 patients (4.9%). Compared to traditionally timed closure (8-12 weeks), reported stoma-related complication rates were lower in patients undergoing early closure. Both mortality and ileus/SBO rates also compare favorably with traditionally timed closure; however, wound infection rates appear to be increased. Additional studies to accurately define which individuals stand to benefit from early closure, as well as to further evaluate the impact of early ileostomy closure on quality of life and health care costs, are warranted.

Improving surgical intravenous fluid management: a controlled educational study

BACKGROUND

This study aims to measure whether the introduction of a multifaceted, evidence-based, educational intervention will improve both intravenous (i.v.) fluids prescribed by doctors and administrated by nurses.

METHODS

A daily baseline audit of i.v. fluid prescription and administration for colorectal inpatients was carried out at two Auckland teaching hospitals over 4 weeks. The educational intervention was then administered at hospital 1, while at hospital 2 nurses and junior doctors were merely informed of the audit. The educational intervention included a lecture, multiple posters around the wards and pocket i.v. fluid protocols for junior doctors. Data collection continued for a further 4 weeks at both sites.

RESULTS

The study included 513 days of i.v. fluids received by 109 patients at the two sites. At hospital 1 following the intervention, there was an improvement in the number of correct prescriptions of maintenance i.v. fluids from 21% to 62% (P < 0.001). There were also improvements in the number of patients who received correct administration of i.v. maintenance fluids from 26% to 57% (P < 0.001), gastric loss i.v. replacement from 61% to 93% (P < 0.001) and bowel loss i.v. replacement fluids from 59% to 85% (P = 0.004). None of these measures improved at hospital 2.

CONCLUSION

At baseline, both prescription and administration of i.v. fluids were poor. A multifaceted educational intervention, involving teaching sessions with handouts, pocket-sized cards and posters visible on the wards, has brought improvements to both the prescription and administration of i.v. fluids in patients managed by colorectal surgeons.