Multi-institutional assessment of sphincter preservation for rectal cancer.

BACKGROUND: Sphincter-preserving surgery (SPS) has been proposed as a quality measure for rectal cancer surgery. However, previous studies on SPS rates lack critical clinical characteristics, rendering it unclear if variation in SPS rates is due to unmeasured case-mix differences or surgeons' selection criteria. In this context, we investigate the variation in SPS rates at various practice settings. METHODS: Ten hospitals in the Michigan Surgical Quality Collaborative collected rectal cancer-specific data, including tumor location and reasons for non-SPS, of patients who underwent rectal cancer surgery from 2007 to 2012. Hospitals were divided into terciles of SPS rates (frequent, average, and infrequent). Patients were categorized as 'definitely SPS eligible' a priori if they did not have any of the following: sphincter involvement, tumor <6 cm from the anal verge, fecal incontinence, stoma preference, or metastatic disease. Fixed-effects logistic regression was used to evaluate for factors associated with SPS. RESULTS: In total, 329 patients underwent rectal cancer surgery at 10 hospitals (5/10 higher volume, and 6/10 major teaching). Overall, 72 % had SPS (range by hospital 47-91 %). Patient and tumor characteristics were similar between hospital terciles. On multivariable analysis, only hospital ID, younger age, and tumor location were associated with SPS, but not sex, race, body mass index, American Joint Committee on Cancer (AJCC) stage, preoperative radiation, or American Society of Anesthesiologists (ASA) class. Analysis of the 181 (55 %) 'definitely-eligible' patients revealed an SPS rate of 90 % (65-100 %). CONCLUSIONS: SPS rates vary by hospital, even after accounting for clinical characteristics using detailed chart review. These data suggest missed opportunities for SPS, and refute the general hypothesis that hospital variation in previous studies is due to unmeasured case-mix differences.

Perineal Crohn's disease: an indicator of poor prognosis and potential proctectomy.

PURPOSE: There is a subset of patients with perianal Crohn's disease whose course is unusually severe. The hypotheses of this study are that these patients often have direct perineal involvement with Crohn's disease and that this involvement can be recognized clinically. METHODS: A prospective database with data from 1989 to 2005 was examined for patients with perianal Crohn's disease. Patients were divided into those with and those without perineal involvement, defined by the presence of at least one of the following findings: spontaneous perineal ulceration; nonhealing, painless fissures; or waxy perineal edema. Presentation, treatment, and outcome of the two groups were compared. RESULTS: Seventy-two patients were identified, 19 with perineal involvement and 63 without. Perineal Crohn's disease was more often seen in women, presented at a younger age, and was associated with less small bowel and more colonic Crohn's. The chances of healing in patients with perineal Crohn's disease were lower (32 vs. 66 percent) and proctectomy was more likely (26 vs. 3.7 percent) than when the perineum was normal. CONCLUSION: Perineal involvement with Crohn's disease can be diagnosed on physical examination and confirmed by the finding of granulomas. When perineal involvement is suspected, surgery should be avoided and consideration given to medical therapy.

Clinical efficacy of serial computed tomographic scanning in pediatric severe traumatic brain injury.

The purpose of this study is to determine whether serial computed tomography (CT) scans of the head lead to operative intervention in pediatric patients with severe traumatic brain injury (TBI). Serial CT scans are those done in addition to the initial CT scan and one follow up CT scan in the first 24-48 h. This study is a retrospective review from January 1990 to December 2003. The hospital course was reviewed for 942 pediatric patients with traumatic brain injuries. Of these, 40 patients were identified who met the following criteria: age less than 18, admission, Glasgow Coma Scale (GCS) < or = 8, intra-cranial pressure (ICP) monitoring during hospitalization, no craniotomy at admission, and at least one serial CT scan after the first 48 h. One hundred fifteen serial CT scans were ordered. Eighty-seven were ordered for routine follow up, 24 were ordered for increased ICP, and 4 were ordered for neurologic change. One craniotomy and one burr hole were performed based on serial CT scans ordered for increased ICP. Serial CT scans, beyond the initial and follow-up scans, have a limited role in children with severe TBI. In this series, only serial CT scans ordered for increased ICP (21%) and neurologic deterioration (3%) led to operative interventions. Serial scans ordered for routine follow-up (76%) resulted in no operative interventions.

Clinical efficacy of serial computed tomographic scanning in severe closed head injury patients.

BACKGROUND: The purpose of this study was to determine whether serial computed tomographic (CT) scans of the head serve to prompt operative intervention. After the initial and 24- to 48-hour repeat scans, if no operative intervention has been performed, further serial scans are ordered on a planned basis or on the basis of changes in clinical status. METHODS: This study is a retrospective review from January 1996 to December 2000. Results of the initial, follow-up, and serial CT scans were recorded for the 51 patients who met the inclusion/exclusion criteria. RESULTS: One hundred seventeen (53.4%) serial CT scans were ordered. No urgent operative interventions were performed on the basis of the serial CT scans. Three scans (2.56%) led to nonurgent neurosurgical intervention. CONCLUSION: In severe head-injured patients who are nonneurosurgical candidates on the basis of initial and repeat CT scans, serial head CT scans have little clinical efficacy and do not lead to urgent operative intervention.