Postoperative Adverse Events Inconsistently Improved by the World Health Organization Surgical Safety Checklist: A Systematic Literature Review of 25 Studies.

BACKGROUND: The World Health Organization Surgical Safety Checklist (SSC) has been widely implemented in an effort to decrease surgical adverse events. METHOD: This systematic literature review examined the effects of the SSC on postoperative outcomes. The review included 25 studies: two randomised controlled trials, 13 prospective and ten retrospective cohort trials. A meta-analysis was not conducted as combining observational studies of heterogeneous quality may be highly biased. RESULTS: The quality of the studies was largely suboptimal; only four studies had a concurrent control group, many studies were underpowered to examine specific postoperative outcomes and teamwork-training initiatives were often combined with the implementation of the checklist, confounding the results. The effects of the checklist were largely inconsistent. Postoperative complications were examined in 20 studies; complication rates significantly decreased in ten and increased in one. Eighteen studies examined postoperative mortality. Rates significantly decreased in four and increased in one. Postoperative mortality rates were not significantly decreased in any studies in developed nations, whereas they were significantly decreased in 75 % of studies conducted in developing nations. CONCLUSIONS: The checklist may be associated with a decrease in surgical adverse events and this effect seems to be greater in developing nations. With the observed incongruence between specific postoperative outcomes and the overall poor study designs, it is possible that many of the positive changes associated with the use of the checklist were due to temporal changes, confounding factors and publication bias.

Supplementary home biofeedback improves quality of life in younger patients with fecal incontinence.

BACKGROUND: Biofeedback is a scarce, resource-intensive clinical therapy. It is used to treat patients with bowel problems, including fecal incontinence (FI), who fail to respond to simple dietary advice, medication, or pelvic floor exercises. Populations are aging and younger cohorts use technology in managing their health, affording FI self-management opportunities. AIM: Does supplementary home-based biofeedback improve FI and quality of life (QOL)? METHODS: Seventy-five incontinent participants (12 male), mean age 61.1 years, consented to participate. Thirty-nine patients (5 male) were randomized to the standard biofeedback protocol plus daily home use of a Peritron perineometer (intervention) and 36 patients (7 male) to the standard biofeedback protocol (control). On completion of the study each perineometer exercise session was rated for technique by 2 raters, blinded to the patient and order of sessions. RESULTS: With the exception of Fecal Incontinence Quality of Life Scale lifestyle improvement (intervention--9.1% vs. controls--0.3%, P=0.026) and embarrassment improvement (intervention--50.0% vs. controls--18.3%, P=0.026), supplementary home biofeedback did not result in greater clinical improvement for the intervention group as a whole. However, on stratification around the mean age, continence and QOL of younger people in the intervention group were significantly better than those of their control counterparts. Graphed perineometer sessions demonstrated high compliance and improvement in exercise technique. Perineometers provided reassurance, motivation, and an exercise reminder ensuring that confidence was achieved quickly. CONCLUSIONS: Home biofeedback was acceptable and well tolerated by all users. Younger participants significantly benefited from using this technology.

Faecal incontinence in rural and regional northern Queensland community-dwelling adults.

INTRODUCTION: In Australia, faecal incontinence, the involuntary loss of liquid or solid stool with or without a person's awareness, has been reported in 8% of the South Australian and 11% of the urban New South Wales community-dwelling populations. Studies conducted in 2004 and 2005 reported faecal incontinence in more than 20% of colorectal and urogynaecological clinic patients at Townsville Hospital (a referral centre serving rural North Queensland). This prompted concern regarding the level of faecal incontinence in the community. The aim of this study was to investigate the prevalence of faecal incontinence in the North and Far North Queensland urban and rural communities. METHODS: The sample size was based on the New South Wales postal surveys (11% prevalence). Higher rates were expected in North/Far North Queensland, so prevalence there was estimated at 12.1% (confidence interval ± 2%, ie the true level to be between 10.1% and 14.1%). The sample for each of the Townsville, Cairns (in Far North Queensland) and rural/remote settings was calculated at 1022. The database for the present study was compiled using a systematic randomised process selecting two private names from each column on each page of the Cairns and Townsville White Pages® (Cairns: 1112 urban, 481 rural, 226 remote; Townsville: 1049 urban, 432 rural, 320 remote). The questionnaire covered personal demographics, health/risk factors, bowel habits, nutrition (fibre and fluid intake) and physical activity. Faecal incontinence was defined as accidental leakage of solid or liquid stool in the past 12 months that was not caused by a virus, medication or contaminated food. To improve the response rate a participation incentive of a chance to win a $250 voucher or one of ten $50 vouchers was offered in the initial mail-out. The initial survey was mailed out in July 2007; two follow-up surveys were mailed out to non-responders in September 2007 and January 2008. One hundred randomly selected non-responders were telephoned in February 2008. RESULTS: A total of 1523 responses provided a 48.1% response rate. Faecal incontinence prevalence was 12.7% (174/1366) with no gender or locality differences. Prevalence increased significantly with age in men (p=0.034), but not in women. Only 10 respondents with faecal incontinence consulted their doctor in the previous year for this reason. Incontinent respondents had significantly more medical conditions including urinary incontinence, coeliac disease, irritable bowel syndrome, injury to the anus, bowel cancer, spinal cord disease, neurological disease and psychiatric problems (all, p< 0.05). Stool-related accidental bowel leakage including faecal incontinence (defined), soiling with flatus or urgency, was 18.2%. An additional 3% were possibly incontinent, having disclosed leakage of mucus, bothersome or passive staining. Of the remaining respondents, 16.2% reported incontinent episodes due to an acute illness, 22.9% could not always differentiate between flatus and stool, and only 35.2% reported neither concerns with nor accidental bowel leakage. CONCLUSIONS: There is a high level of untreated faecal incontinence in North/Far North Queensland communities. Demand for treatment will increase because of the ageing population and the expectations of younger, more assertive cohorts.

Glyceryl trinitrate ointment did not reduce pain after stapled hemorrhoidectomy: a randomized controlled trial.

Medications, including topical 0.2% glyceryl trinitrate (GTN), can reduce anal spasm and pain after excisional hemorrhoidectomy. GTN after stapled hemorrhoidopexy was compared with routine postoperative management. Patients with symptomatic grade 3/4 hemorrhoids were recruited. After stapled hemorrhoidopexy, residual perianal skin tags were excised as appropriate. Those requiring double purse-string mucosectomy were excluded. Postoperative pain, pain duration, and complications were assessed. One hundred ten patients (74 men; mean age 50.6 years) were enrolled in the control group and 100 patients (57 men; mean age 49.8 years) in the GTN group. Maximum pain was higher in the GTN group (P  =  0.015). There were no differences between the two groups in residual perianal skin tags requiring excision, postoperative complications, recurrence rates, follow-up period, average pain, duration of pain, or satisfaction scores. Sixteen GTN patients were noncompliant due to side effects. None had persistent perianal skin tags. GTN did not reduce postoperative pain after stapled hemorrhoidectomy.

Ligation of intersphincteric fistula tract compared with advancement flap for complex anorectal fistulas requiring initial seton drainage.

BACKGROUND: The ligation of intersphincteric fistula tract (LIFT) is a relatively new surgical technique for treating complex anorectal fistulas. METHODS: LIFT was compared with anorectal advancement flap management (ARAF) of complex anorectal fistulas requiring previous seton drainage. Crohn's patients were excluded. Patients with no confirmed recurrent sepsis after 6 months were randomized to day surgery performance of LIFT (25; 17 male) or ARAF (14; 10 male) with removal of the seton. Outcome measures included recurrences, surgical time, complications, hospital readmissions, and fecal incontinence. RESULTS: LIFT was 32.5 minutes shorter than ARAF (P < .001). Complications were similar, with no hospital readmissions. Return to normal activities was 1 week for LIFT patients, 2 weeks for ARAF patients (P = .016). At 19 months there were 3 recurrences (2 in the LIFT group). One ARAF patient had minor incontinence. CONCLUSIONS: The LIFT procedure was simple, safe, shorter, and patients returned to work earlier. All patients had preliminary seton drainage, possibly contributing to the low recurrence rates.

Biofeedback for fecal incontinence: a randomized study comparing exercise regimens.

BACKGROUND: Fecal incontinence affects up to 11% of Australian community-dwelling adults and 72% of nursing home residents. Biofeedback is a recommended conservative therapy when medication and pelvic floor exercises have failed to improve patient outcomes. OBJECTIVE: This study aimed to investigate the impact of a new exercise regimen on the severity of fecal incontinence and the quality of life of participants. DESIGN: This was a randomized clinical study. SETTINGS: This study was conducted at the Anorectal Physiology Clinic, Townsville Hospital, Queensland, Australia. PATIENTS: Seventy-two participants (19 male), with a mean age of 62.1 years, attended 5 clinic sessions: 4 weekly sessions followed by 4 weeks of home practice and a follow-up assessment session. A postal survey was conducted 2 years later. INTERVENTION: Thirty-seven patients (12 male) were randomly assigned to the standard clinical protocol (sustained submaximal anal and pelvic floor exercises) and 35 patients (7 male) were randomly assigned to the alternative group (rapid squeeze plus sustained submaximal exercises). MAIN OUTCOME MEASURES: The main outcomes were measured by use of the Cleveland Clinic Florida Fecal Incontinence score and the Fecal Incontinence Quality of Life Scale survey tool. RESULTS: No significant differences were found between the 2 exercise groups at the beginning or at the end of the study or as a result of treatment in objective, quality-of-life, or fecal incontinence severity measures. Sixty-nine participants completed treatment. The severity of fecal incontinence decreased significantly (11.5/20 to 5.0/20, P < .001). Eighty-six percent (59/69) of participants reported improved continence. Quality of life significantly improved for all participants (P < .001). Results were sustained 2 years later. Patients who practiced at least the prescribed number of exercises had better outcomes than those who practiced fewer exercises. LIMITATIONS: This study was limited because it involved a heterogeneous sample, it was based on subjective reporting of exercise performance, and loss to follow-up occurred because of the highly mobile population. CONCLUSIONS: Patients attending this biofeedback program attained significant improvement in the severity of their fecal incontinence and in their quality of life. Although introduction of rapid muscle squeezes had little impact on fecal incontinence severity or patient quality of life, patient exercise compliance at prescribed or greater levels did.

Practical strategies for treating postsurgical bowel dysfunction.

Postsurgical bowel dysfunction is a potential complication for patients undergoing ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis. In our setting, these patients are referred to the Anorectal Physiology Clinic at the Townsville Hospital, Queensland, for comprehensive behavioral therapy. The goals of the therapy are as follows: improve stool consistency, improve control over stool elimination, decrease fecal frequency and rectal urgency, fecal continence without excessive restrictions on food and fluid intake, and increase quality of life. This article outlines our holistic approach and specific treatment strategies, including assessment, education, support and assistance with coping, individualized dietary and fluid modifications, medications, and exercise. Biofeedback is used to help patients improve anal sphincter and pelvic floor muscle function and bowel elimination habits. Information on the biofeedback component of the treatment program will be described in a subsequent article.

Impact of fecal incontinence on quality of life.

AIM: To explore the impact of fecal incontinence (FI) on quality of life (QOL) of patients attending urogynecology and colorectal clinics (CCs). METHODS: Cross-sectional study of 154 patients (27 male) with FI, who attended the clinics at a regional hospital in North Queensland, Australia in 2003 and 2004, and completed the Fecal Incontinence Quality of Life Scale (FIQL: 1 = very affected; 4 = not affected). RESULTS: More than 22% of patients had their QOL affected severely by FI. Patients reported that they had not previously been asked about FI by a medical practitioner nor did they voluntarily disclose its presence. The median FIQL scores for all participants were: lifestyle = 3.24; coping = 2.23; depression = 2.42; and embarrassment = 2.33. Increasing frequency of soiling had a negative effect on all four FIQL scales (P < 0.001) as did the quantity of soiling (P < 0.01). Female CC patients had poorer FIQL scores than urogynecology clinic patients for lifestyle (P = 0.015), coping (P = 0.004) and embarrassment (P = 0.009), but not depression (P = 0.062), despite having experienced FI for a shorter period. CONCLUSION: Failure to seek treatment for FI degrades the quality of patients' lives over time. FI assessment tools should incorporate the quantity of fecal loss.