Gastroenterologist and surgeon perceptions of recommendations for optimal endoscopic localization of colorectal neoplasms.

National consensus recommendations have recently been developed to standardize colorectal tumour localization and documentation during colonoscopy. In this qualitative semi-structured interview study, we identified and contrast the perceived barriers and facilitators to using these new recommendations according to gastroenterologists and surgeons in a large central Canadian city. Interviews were analyzed according to the Consolidated Framework for Implementation Research (CFIR) through directed content analysis. Solutions were categorized using the Expert Recommendations for Implementing Change (ERIC) framework. Eleven gastroenterologists and ten surgeons participated. Both specialty groups felt that the new recommendations were clearly written, adequately addressed current care practice tensions, and offered a relative advantage versus existing practices. The new recommendations appeared appropriately complex, applicable to most participants, and could be trialed and adapted prior to full implementation. Major barriers included a lack of relevant external or internal organizational incentives, non-existing formal feedback processes, and a lack of individual familiarity with the evidence behind some recommendations. With application of the ERIC framework, common barriers could be addressed through accessing new funding, altering incentive structures, changing record systems, educational interventions, identifying champions, promoting adaptability, and employing audit/feedback processes. Future research is needed to test strategies for feasibility and effectiveness.

Early Surveillance Endoscopy Should Be Performed Selectively After Transanal Endoscopic Microsurgery for Rectal Lesions.

Introduction Local recurrence (LR) rates after transanal endoscopic microsurgery (TEM) are unclear, and the utility of early postoperative surveillance for low-risk lesions is unknown. This study aimed to define LR after TEM for benign polyps and invasive adenocarcinoma, describe risk factors for LR, and evaluate the utility of early surveillance endoscopy. Methods This retrospective cohort study was conducted at two hospitals in Winnipeg, Manitoba, Canada. Adult patients who underwent TEM between 2009 and 2020 were evaluated for inclusion. The primary outcome was the rate of LR on surveillance endoscopy. Other outcomes included risk factors for LR and diagnostic yield of surveillance endoscopy. Results Among 357 patients who underwent TEM for benign polyps, LR was 10.5% (95% confidence interval (CI) 5.8-15.2) at three years. Positive margin was correlated with LR on multivariate analysis (hazard ratio (HR) 8.01, 95% CI 2.78-23.08). TEM defect closure was associated with lower LR on multivariate analysis (HR 0.19, 95% CI 0.06-0.59). Among 124 patients who underwent TEM for rectal adenocarcinoma, LR was 15.0% (95% CI 6.0-24.0) at three years. The first surveillance endoscopy had a 1.4% yield for low-risk patients (benign lesion, negative margins, and closed TEM defect) and 6.9% for all others. Conclusions LR at three years after TEM was 10.5% for benign polyps and 15.0% for adenocarcinomas. Early surveillance endoscopy can be considered low yield in some patients after TEM, which can be informative for shared decision-making regarding whether to proceed with early endoscopy in a low-risk subgroup of patients.

Total neoadjuvant therapy for rectal cancer: a guide for surgeons.

The modern management of rectal cancers continues to evolve. With the release of data from new landmark randomized controlled trials (RAPIDO, PRODIGE-23), total neoadjuvant therapy (TNT) has moved to the forefront of locally advanced rectal cancer treatment and is considered a standard option in selected patients. Total neoadjuvant therapy promises enhanced systemic disease control, better treatment adherence and less time with an ostomy. However, TNT as currently described encompasses a number of different potential treatment options that differ significantly in terms of their radiation dosage, chemotherapy regimen and order of treatments administered. Being familiar with TNT regimens will be important for rectal cancer surgeons to appropriately advocate for their patients and optimize their outcomes. This article serves as a primer for the general surgeon and offers a pragmatic overview of the indications, realistic expected benefits and potential downsides of each TNT regimen.

Optimal endoscopic localization of colorectal neoplasms: a comparison of rural versus urban documentation practices.

BACKGROUND: Colonoscopy is the gold standard for diagnosing colorectal neoplasms. However, colonoscopy is often repeated preoperatively due to non-standard documentation and inconsistent practices by index endoscopists. Repeat endoscopies result in treatment delays and can increase risks of complications. National consensus recommendations were recently developed for optimal endoscopic colorectal lesion localization. We aimed to assess baseline colonoscopy practice differences from the new recommendations with a focus on geographical variability in report quality between urban and rural referral sites. METHODS: We performed a retrospective review of patients who underwent elective surgery for colorectal neoplasms at a single institution in Winnipeg between 2007-2020. We compared endoscopy report quality to the national recommendations with charts stratified by endoscopy location. Our primary outcomes were overall report documentation completeness and use of recommended practices. RESULTS: One hundred ninety-four patients were included (97 rural, 97 urban). The mean overall compliance with the recommendations for urban endoscopies was marginally better compared to rural endoscopies (50% vs. 48%, p = 0.04). Sixty-eight percent of the reports complied with tattoo indications (72% urban; 63% rural, p = 0.16). On average, reports included 29% of recommended tattoo information (30% urban; 28% rural, p = 0.25) and demonstrated 74% appropriate tattoo technique (70% urban; 81% rural, p = 0.10). Twenty-one percent of reports included photographs of lesions in accordance with the national recommendations (28% urban; 13% rural, p = 0.01). CONCLUSIONS: Endoscopists frequently omit recommended practices for optimal colorectal lesion localization. Rural reports miss more recommended information compared to urban reports. Future research is needed to facilitate province-wide high-quality endoscopy reporting for patients regardless of endoscopy location.

Variability in Communication and Reporting Practices Between Gastroenterologists and General Surgeons Contributes to Repeat Preoperative Endoscopy for Colorectal Neoplasms: A Qualitative Analysis.

BACKGROUND: Surgeons commonly repeat preoperative endoscopy before planned colorectal resections. The reasons for this are not entirely clear, and repeat endoscopy may lead to delays in curative resection, increased costs, and patient discomfort. OBJECTIVE: This study aimed to determine practice patterns, localization techniques, and processes of communication undertaken by endoscopy specialists in a high-volume regional health authority. DESIGN: This was a qualitative study involving standardized, semi-structured, in-depth interviews that were conducted in person. Data were analyzed using a thematic analysis approach. SETTINGS: The study was conducted at Canadian tertiary and community facilities. PARTICIPANTS: Ten general surgeons and 10 gastroenterologists were included using a convenience sampling technique. MAIN OUTCOME MEASURES: Interview questions were developed to understand the perspectives and practice patterns of endoscopists when approaching patients diagnosed with colorectal lesions requiring surgical resection. The decision-making process to perform a repeat preoperative endoscopy was assessed. RESULTS: Three key themes emerged: 1) patterns of communication, 2) feedback, and 3) trust. Thematic analysis revealed that poor communication and ambiguous documentation increased the likelihood of performing repeat preoperative endoscopy. Inconsistencies in tattooing practices and lesion location were important factors. Negative experiences and factors related to interprofessional trust emerged as key contributors to repeat preoperative endoscopy. LIMITATIONS: The transferability of findings to health care systems outside Canada may be limited and requires further study. CONCLUSIONS: Suboptimal endoscopic reporting contributes to gaps in communication among endoscopists. In addition, lack of consistent feedback and mutual trust may increase the likelihood of performing repeat preoperative lower endoscopy. Inconsistent tattooing practices pose significant concerns for accurate intraoperative lesion localization. Establishing collaborative work environments through joint educational initiatives may enhance communication and mitigate unnecessary repeat procedures. These results support the need for standardized guidelines and endoscopic reporting in the management of colorectal lesions. See Video Abstract at http://links.lww.com/DCR/B879 . LA VARIABILIDAD EN LAS PRCTICAS DE COMUNICACIN Y PRESENTACIN DE INFORMES ENTRE GASTROENTERLOGOS Y CIRUJANOS GENERALES CONTRIBUYE A REPETIR LA ENDOSCOPIA PREOPERATORIA PARA LAS NEOPLASIAS COLORRECTALES UN ANLISIS CUALITATIVO: ANTECEDENTES:Los cirujanos suelen repetir la endoscopia preoperatoria antes de las resecciones colorrectales planificadas. Las razones de esto no están del todo claras y la repetición de la endoscopia puede provocar retrasos en la resección curativa, aumento de los costos y malestar del paciente.OBJETIVO:Nuestro objetivo fue determinar patrones de práctica, técnicas de localización y procesos de comunicación realizados por especialistas en endoscopia, en una autoridad sanitaria regional, de alto volumen.DISEÑO:Este fue un estudio cualitativo, que involucró entrevistas estandarizadas, semiestructuradas y en profundidad que se llevaron a cabo en persona. Los datos se analizaron mediante un enfoque de análisis temático.ENTORNO CLINICO:El estudio se llevó a cabo en instalaciones comunitarias y terciarias canadienses.PARTICIPANTES:Se incluyeron 10 cirujanos generales y 10 gastroenterólogos, utilizando una técnica de muestreo por conveniencia.PRINCIPALES MEDIDAS DE VALORACION:Las preguntas de la entrevista se desarrollaron para comprender las perspectivas y los patrones de práctica de los endoscopistas, cuando se acercan a pacientes diagnosticados con lesiones colorrectales que requieren resección quirúrgica. Se evaluó el proceso de toma de decisiones para realizar una nueva endoscopia preoperatoria.RESULTADOS:Surgieron tres temas clave: 1) patrones de comunicación, 2) retroalimentación y 3) confianza. El análisis temático reveló que la pobre comunicación y la ambigua documentación aumentaron la probabilidad de realizar una nueva endoscopia preoperatoria. Las inconsistencias en las prácticas de tatuaje y la ubicación de las lesiones fueron factores importantes. Las experiencias pasadas negativas y los factores relacionados con la confianza interprofesional surgieron como contribuyentes clave para repetir la endoscopia preoperatoria.LIMITACIONES:La transferibilidad de los hallazgos a los sistemas de atención médica fuera de Canadá, puede ser limitada y requiere más estudios.CONCLUSIONES:Los informes endoscópicos subóptimos contribuyen a las brechas en la comunicación entre los endoscopistas. Además, la falta de retroalimentación consistente y la confianza mutua pueden aumentar la probabilidad de realizar una nueva endoscopia baja preoperatoria. Las prácticas inconsistentes de tatuaje, plantean preocupaciones importantes para la localización precisa de las lesiones intraoperatorias. El establecimiento de entornos de trabajo colaborativo a través de iniciativas educativas conjuntas pueden mejorar la comunicación y mitigar la repetición de procedimientos innecesarios. Estos resultados apoyan la necesidad de pautas estandarizadas e informes endoscópicos en el tratamiento de las lesiones colorrectales. Consulte Video Resumen en http://links.lww.com/DCR/B879 . (Traducción-Dr. Fidel Ruiz Healy ).

Recommendations for Optimal Endoscopic Localization of Colorectal Neoplasms: A Delphi Consensus of National Experts.

BACKGROUND: Colonoscopy is the standard of care for diagnosis and evaluation of colorectal cancers before surgery. However, varied practices and heterogenous documentation affects communication between endoscopists and operating surgeons, hampering surgical planning. OBJECTIVE: This study aimed to develop recommendations for the use of standardized localization and reporting practices for colorectal lesions identified during lower GI endoscopy. DESIGN: A systematic review of existing endoscopy guidelines and thorough narrative review of the overall endoscopy literature were performed to identify existing practices recommended globally. SETTING: An online Delphi process was used to establish consensus recommendations based on a literature review. PATIENTS: Colorectal surgeons and gastroenterologists from across Canada who had previously demonstrated leadership in endoscopy, managed large endoscopy programs, produced high-impact publications in the field of endoscopy, or participated in the development of endoscopy guidelines were selected to participate. PRIMARY OUTCOME MEASURES: The primary outcomes measured were colorectal lesion localization and documentation practice recommendations important to planning surgical or advanced endoscopic excisions. RESULTS: A total of 129 of 197 statements achieved consensus after 3 rounds of voting by 23 experts from across Canada. There was more than 90% participation in each round. Recommendations varied according to lesion location in the cecum, colon, or rectum and whether the referral was planned for surgical or advanced endoscopic resection. Recommendations were provided for appropriate documentation, indications, location, and method of tattoo placement, in addition to photograph and real-time 3-dimensional scope configuration device use. LIMITATIONS: Because of a paucity of evidence, recommendations are based primarily on expert opinion. There may be bias, as all representatives were based in Canada. CONCLUSIONS: Best practices to optimize endoscopic lesion localization and communication are not addressed in previous guidelines. This consensus involving national experts in colorectal surgery and gastroenterology provides a framework for efficient and effective colorectal lesion localization. See Video Abstract at http://links.lww.com/DCR/C71 . RECOMENDACIONES PARA LA LOCALIZACIN ENDOSCPICA PTIMA DE LAS NEOPLASIAS COLORRECTALES UN CONSENSO DELPHI DE EXPERTOS NACIONALES: ANTECEDENTES:La colonoscopia es el estándar de atención para el diagnóstico y la evaluación de los cánceres colorrectales antes de la cirugía. Sin embargo, las prácticas variadas y la documentación heterogénea afectan la comunicación entre los endoscopistas y los cirujanos operadores, lo que dificulta la planificación quirúrgica.OBJETIVO:Este estudio tuvo como objetivo desarrollar recomendaciones para el uso de prácticas estandarizadas de localización y notificación de lesiones colorrectales identificadas en la endoscopia gastrointestinal inferior.DISEÑO:Se realizó una revisión sistemática de las pautas de endoscopia existentes y una revisión narrativa exhaustiva de la literatura general sobre endoscopia para identificar las prácticas existentes recomendadas a nivel mundial. Se utilizó un proceso Delphi en línea para establecer recomendaciones de consenso basadas en la revisión de la literatura.PARTICIPANTES:Se seleccionaron para participar cirujanos colorrectales y gastroenterólogos de todo Canadá que previamente habían demostrado liderazgo en endoscopia, manejado grandes programas de endoscopia, producido publicaciones de alto impacto en el campo de la endoscopia o que habían participado en el desarrollo de pautas de endoscopia.RESULTADOS:Localización de lesiones colorrectales y recomendaciones prácticas de documentación importantes para planificar escisiones quirúrgicas o endoscópicas avanzadas.RESULTADOS:129 de 197 declaraciones lograron consenso después de tres rondas de votación de 23 expertos de todo Canadá. Hubo >90% de participación en cada ronda. Las recomendaciones variaron según la ubicación de la lesión en el ciego, colon o recto, y si se planificó la derivación para resección quirúrgica o endoscópica avanzada. Se proporcionaron recomendaciones para la documentación adecuada, las indicaciones, la ubicación y el método de colocación del tatuaje, además de la fotografía y el uso del dispositivo de configuración del alcance 3D en tiempo real.LIMITACIONES:Debido a la escasez de evidencia, las recomendaciones se basan principalmente en la opinión de expertos. Puede haber sesgo, ya que los representantes tenían su sede en Canadá.CONCLUSIONES:Las mejores prácticas para optimizar la localización y comunicación de lesiones endoscópicas no se abordan en las guías anteriores. Este consenso que involucra a expertos nacionales en cirugía colorrectal y gastroenterología proporciona un marco para la localización eficiente y efectiva de lesiones colorrectales. Consulte Video Resumen en http://links.lww.com/DCR/C71 . (Traducción-Dr. Mauricio Santamaria ).

Routine pathologic evaluation of circular stapler anastomotic rings is not useful after resection for colorectal cancer: retrospective study and systematic review with meta-analysis.

BACKGROUND: Circular staplers are commonly used for reconstruction after radical resection for colorectal cancer. Pathological analysis of the anastomotic rings is common practice, although the benefits are unclear. The purpose of this study was to evaluate the usefulness of routine histopathological analysis of anastomotic rings in an original series and in a systematic review of the literature. METHOD: The retrospective study was performed at two university-associated academic hospitals in Winnipeg, Canada, including patients investigated for colorectal cancers (within 30 cm of the anal verge) who underwent resection between 2007 and 2020. The systematic review involved Ovid MEDLINE, Embase, Scopus, and Web of Science databases, selecting for adult human studies involving analysis of anastomotic rings in elective colorectal cancer resections. The main outcome measure was the proportion of patients with cancer in the anastomotic ring specimens. The frequency of benign pathology findings and changes to patient management were also examined. RESULTS: Out of 673 eligible patients, 487 were included in the retrospective analysis. No patients had cancer within the anastomotic ring specimens. Twenty-five patients (5.1 per cent) had benign pathological findings within the anastomotic ring specimens, and patient management was never affected. In the systematic review, 27 articles were included in the final analysis out of 5848 records reviewed. The rate of cancer within anastomotic ring specimens was 0.34 per cent, and the rate of change in patient management was 0.19 per cent. CONCLUSION: The likelihood of finding cancer within anastomotic rings is rare and their histopathological examination seldom changes patient management.

Preoperative stoma site marking for fecal diversions (ileostomy and colostomy): position statement of the Canadian Society of Colon and Rectal Surgeons and Nurses Specialized in Wound, Ostomy and Continence Canada.

BACKGROUND: Every year, about 13 000 Canadians undergo an ostomy procedure, which requires stoma site marking to create a well-constructed stoma and prevent stoma-related complications. The Canadian Society of Colon and Rectal Surgeons (CSCRS) and Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) created a position statement to provide evidence-based guidance and techniques for stoma site selection. METHODS: A task force was formed comprising 20 health care professionals (7 colorectal surgeons from the CSCRS and 13 nurses from NSWOCC) with representation from across Canada. A literature review was performed, with the following databases searched from January 2009 to April 2019: MEDLINE, Embase, Cochrane, PubMed, CINAHL and Google Scholar. After the abstracts were screened, 6 task force members created a draft version of the position statement from the articles retained after full-text review. The draft was submitted to the entire task force for comments, and the ensuing modifications were incorporated. Peer reviewers were then recruited from the CSCRS and NSWOCC; a summary of their comments was reviewed by the task force, and modifications were incorporated to produce the final document. RESULTS: The literature search identified 272 papers, of which 58 were reviewed after duplicates were excluded. After full-text review, 18 papers were included to guide the position statement. From these papers, we created a series of 17 steps for stoma site marking. Four general principles were found to be important for stoma site marking: obtain informed consent, identify important patient factors and landmarks, assess the abdomen and mark the most appropriate location. A 1-page enabler document and video were created as teaching aids and to help with dissemination of the information. CONCLUSION: This position statement, associated enabler document and video provide evidence-based guidance for stoma site marking in both emergency and elective settings, and should be used by surgeons and nurses specialized in wound, ostomy and continence to identify optimal stoma sites preoperatively.

Rectal Cancer Metastasis to the Anal Verge: An Unusual Case Presentation and Review of the Literature.

BACKGROUND: Anal metastasis of colorectal adenocarcinoma is very rare, represented by only a handful of case reports in the literature. Previously, reports of metastasis to this region had occurred following a history of anorectal disease, such as anal fistulae. Antecedent trauma to the area from hemorrhoidectomy, fissures, or perineal retractor injury have also been implicated. CASE PRESENTATION: Herein we report the case of 69-year-old man without any history of anal disease presenting with a metachronous metastasis of a colorectal-type adenocarcinoma to the anal verge. He was previously treated for T1N0 rectal adenocarcinoma at the rectosigmoid junction with a low anterior resection 5 years prior, then had a T3N0 local recurrence at the colorectal anastomosis treated with neoadjuvant chemoradiation, and eventually a Hartmann's procedure 4 years later. Subsequently, on surveillance flexible sigmoidoscopy, a new tumor was identified on the perianal skin extending from the anal verge. Histopathology demonstrated colorectal-type adenocarcinoma. Flexible endoscopy identified no other residual or recurrent disease in the colon or rectal stump. The patient was treated with wide local excision and advancement flap reconstruction. CONCLUSION: Isolated metastasis to the anus is an extremely rare occurrence for colorectal adenocarcinoma. There exists little evidence to inform management. One option is to treat like a locally recurrent rectal cancer with aggressive tri-modality management consisting of chemoradiation, abdominal perineal resection, and adjuvant chemotherapy. In the absence of metastatic disease, local resection and close surveillance remain an option. As always, patient factors should guide management.

Rates and predictors of repeat preoperative endoscopy for elective colorectal resections: how can we avoid repeated procedures?

BACKGROUND: Despite limited endoscopy resources, repeat endoscopy prior to surgery is commonly practised. Our aim was to determine repeat preoperative endoscopy rates and factors influencing this practice at a high-volume Canadian tertiary centre. METHOD: A retrospective cohort study was conducted on all patients undergoing elective colorectal resections for benign and malignant neoplasms at a tertiary centre in Winnipeg, Canada between 2007 and 2017. Multivariable logistic regression analysis was used to identify predictors of repeat preoperative endoscopy. RESULTS: Of 1062 patients identified, mean age was 68 years and 56% were male. Rate of repeat preoperative endoscopy was 29%. On multivariable analysis, male sex (OR 1.68, CI 1.19-2.34, p = 0.003) and lesions located in the left colon (OR 2.73, CI 1.79-4.14, p < 0.001), rectosigmoid (OR 9.11, CI 2.14-38.8, p = 0.003), and rectum (OR 4.06, CI 2.58-6.38, p < 0.001) were at increased odds of undergoing repeat preoperative endoscopy. Patients with a tattoo placed at index endoscopy were at markedly lower odds of undergoing repeat preoperative endoscopy (OR 0.48, CI 0.34-0.68, p < 0.001). Index endoscopist specialty was not a significant predictor of repeat endoscopy (OR 0.76, CI 0.54-1.06, p = 0.09). CONCLUSIONS: Repeat preoperative lower endoscopy is commonly practised and may be unnecessary if appropriate identification and documentation of lesions has been achieved. Tattooing of suspicious lesions is a key modifiable factor associated with reduced likelihood of repeat preoperative endoscopy. This study highlights the need for standardized guidelines and endoscopy reporting practices given the delays and costs associated with repeat preoperative endoscopy.

Repeat preoperative endoscopy after regional implementation of electronic synoptic endoscopy reporting: a retrospective comparative study.

BACKGROUND: Repeat preoperative endoscopy is common for patients with colorectal neoplasms. This can result in treatment delays, patient discomfort, and risks of colonoscopy-related complications. Repeat preoperative endoscopy has been attributed to poor communication between endoscopists and surgeons. In January 2019, mandatory electronic synoptic reporting for endoscopy was implemented to include elements consistent with quality indicators proposed in national guidelines. The aim of the present study is to assess whether the repeat preoperative endoscopy rate for colorectal lesions changed following synoptic report implementation. METHODS: A retrospective review was performed of 1690 consecutive patients who underwent elective surgical resection for colorectal neoplasms from January 2007 to June 2020 at a tertiary hospital in Canada. Patients who had an index endoscopy documented via synoptic report were compared to those reported via narrative report. Primary outcomes were rates of repeat preoperative endoscopy and inclusion of colonoscopy quality indicators: photo-documentation, tattoo placement, and bowel preparation score. RESULTS: In total, 1429 patients who underwent elective colorectal resection for colorectal cancers or polyps between January 2007 and June 2020 were included. 115 had index endoscopies recorded via synoptic report and 1314 by narrative report. The repeat preoperative endoscopy rate after endoscopies documented by narrative report was 29.07% (95% CI 26.63-31.61) and 25.22% (95% CI 17.58-34.17%) for synoptic report. Patients whose index endoscopies where performed by a practitioner other than their operating surgeon had a re-endoscopy rate of 36.03% (95% CI 32.82-39.33%) after narrative report and 38.81% (95% CI 27.14-51.50%) for synoptic report. Rates of tattoo placement, photo-documentation, and reporting of bowel preparation quality were all significantly increased with synoptic reports (p ≤ 0.003). CONCLUSIONS: Endoscopy synoptic reports based on current guidelines were not associated with a decrease in rates of repeat pre-operative endoscopy at a high-volume colorectal cancer centre. Future study should examine guideline deficiencies for this purpose and make necessary modifications.

Sampling error in the diagnosis of colorectal cancer is associated with delay to surgery: a retrospective cohort study.

BACKGROUND: Accurate histopathologic diagnosis of colorectal cancer is important for treatment decision-making and timely care. The aim of this study was to measure rates and predictors of sampling errors for biopsy specimens attained at flexible lower gastrointestinal endoscopy, and to determine whether these events lead to a delay in surgical care. METHODS: This is a retrospective observational study of patients who underwent elective resection for colorectal adenocarcinoma between January 2007 and June 2020. Primary outcomes were proportion of incorrectly diagnosed colorectal adenocarcinomas at index endoscopy by histopathology, and time between endoscopy and surgery. Secondary outcomes were predictors of sampling error, and diagnostic yield of repeat endoscopy. RESULTS: Sampling errors occurred in 217/962 (22.6%) flexible endoscopies for colorectal adenocarcinomas. Negative biopsies were associated with a longer median time to surgery (87.6 days, IQR 48.8-180.0) compared to true positive biopsies (64.0 days, IQR 38.0-119.0), p < 0.001. Controlling for lesion location, neoadjuvant therapy, endoscopist specialty, year, and repeat endoscopies, time to surgery remained 1.40-fold longer (p < 0.001) following sampling error. Repeat endoscopy occurred following 62/217 (28.6%) cases of sampling errors, yielding a correct diagnosis of cancer in 38/62 (61.3%) cases. On multivariable analysis, sampling errors were less likely to occur for lesions endoscopists described as suspicious for malignancy (OR 0.12, 95% CI 0.07-0.21) or simple polyps (OR 0.24, 95% CI 0.08-0.70) compared to endoscopically unresectable polyps. CONCLUSIONS: Colorectal cancers are frequently improperly sampled, which may lead to treatment delays for these patients. When cancer is suspected, surgeons should take care to ensure timely management.

Serrated polyps and polyposis of the colon: a brief review for surgeon endoscopists.

Serrated polyps (SPs) were once considered benign, clinically unimportant lesions. However, it is now recognized that through the serrated neoplasia pathway (SNP), SPs play a role in the development of 15%-30% of cases of colorectal cancers (CRC). Furthermore, a high proportion of postcolonoscopy CRCs are believed to arise from SNP. Serrated polyps are classified into hyperplastic polyps, sessile serrated lesions, sessile serrated lesions with dysplasia, traditionally serrated adenomas, and unclassified serrated adenoma, each with a distinct morphological and molecular profile. Despite improved understanding, SPs remain a clinical challenge owing to evolving terminology, frequent pathologic misclassification, endoscopic underdetection, and high rates of incomplete removal. Surgeon endoscopists and surgeons who perform colorectal procedures will undoubtedly come across patients with SPs, and this paper summarizes some of the clinical challenges they will encounter. We also discuss the diagnosis and management of patients with serrated polyposis syndrome (SPS).

A Strangulated Meckel's Diverticulum in an Inguinal Hernia: A Case Report and Literature Review.

BACKGROUND: Meckel's diverticulum is an embryologic remnant of the vitelline duct, occurring in approximately 2% of the adult population. A hernia containing a Meckel's diverticulum is called a Littré's hernia and is rarely reported in the medical literature. Clinically, a Littré's hernia is indistinguishable from a hernia containing small bowel and is often discovered incidentally during a repair. CASE PRESENTATION: Herein, we report a rare case of strangulated Littré's hernia in a patient's right groin. The sac contained a long segment of small bowel in addition to a large Meckel's diverticulum. The bowel was irreducible through the groin incision, and a lower midline laparotomy was made. Necrotic bowel including the Meckel's diverticulum was resected. Given the presence of necrotic bowel and potential for infection, the hernia was repaired with a Bassini herniorrhaphy, reinforced with absorbable mesh. The patient recovered uneventfully. CONCLUSION: Littré's hernia is a rare clinical entity. Treatment is similar to any bowel-containing hernia. Repair of the hernia defect with permanent mesh should be weighed against the risk of implant infection.

Abdominoperineal Resection with Absorbable Mesh Repair of Perineal Defect for Fournier's Gangrene: A Case Report.

BACKGROUND: Fournier's gangrene (FG) is a rare but deadly form of necrotizing fasciitis involving the genital, perineal, and anorectal region. Risk factors include diabetes mellitus, immunosuppression, and alcohol misuse. Because multisystem organ failure can rapidly develop, early diagnosis is critical. Treatment includes fluid resuscitation, broad-spectrum antibiotics, and surgical debridement. Uncommonly, extension of perineal infection into adjacent organs can necessitate multivisceral resection, which can make reconstruction a challenge. Even with swift diagnosis and optimal treatment, morbidity and mortality are high. CASE PRESENTATION: A 66-year-old male with a history of diabetes mellitus presented to the emergency department with progressive scrotal pain, swelling, and perineal skin changes. Examination revealed necrosis of the scrotal soft tissues with involvement of the anal canal and rectum. The patient was initiated on intravenous fluids and broad-spectrum antibiotics, then brought immediately to the operating room where surgical care was provided by a urologist, colorectal surgeon, and general surgeon with expertise in complex mesh repair. Extension of necrotic changes travelling proximally through the full thickness of the rectum was noted. The patient underwent extensive scrotal and perineal debridement, laparotomy, abdominoperineal resection (APR), end colostomy, and polyglactin mesh repair of the resultant pelvic floor defect. The patient had appropriate return of bowel function and satisfactory healing of the perineum postoperatively but ultimately died after a ventricular fibrillation-related cardiac arrest precipitated by a flare of idiopathic pulmonary fibrosis. CONCLUSION: Early diagnosis and referral to the appropriate specialists are essential elements of managing FG. Here we present a case with extension of necrotizing soft tissue infection into the rectum, requiring pelvic dissection and APR as well as absorbable mesh use to aid in perineal closure. Despite expedient treatment, poor outcomes with this condition are unfortunately common.

Predictors and rates of prior endoscopic tattoo localization amongst individuals undergoing elective colorectal resections for benign and malignant lesions.

BACKGROUND: Appropriate tattooing of suspicious lesions during colonoscopy is critical for surgical planning. However, variability exists in tattoo placement, technique, and reporting. Our aim is to determine the rates and predictors of tattoo placement, tattoo location in relation to the lesion, and localization accuracy during lower endoscopy for individuals undergoing elective colorectal resections. METHODS: We performed a retrospective chart review on all patients undergoing elective colorectal resections for benign and malignant neoplasms between 2007 and 2017 at a high volume Canadian tertiary centre. Patient demographics, endoscopic, and tumour-related characteristics were collected. Multivariable logistic regression analysis was used to identify predictors of tattoo localization. RESULTS: Of the 1062 patients identified, laparoscopic resection occurred in 59% of patients. 57% of patients underwent tattooing for tumour localization at index endoscopy. Tattoos were placed distal (27%), both proximal and distal (4%), and just proximal (2%) to the lesion. However, in the majority of cases the tattoo location was not documented (67%). On multivariate analysis, patients who had lesions located in the transverse colon (OR: 1.93, 95% CI 1.04-3.59), had surgery performed after 2010 (2011-2014: OR: 1.88, 95% CI 1.31-2.68; 2015-2017: OR: 2.87, 95% CI 1.93-4.26), underwent laparoscopic resections (OR: 1.69, 95% CI 1.22-2.33), and had their index endoscopy performed in an urban setting (OR: 5.92, 95% CI 3.23-10.87), were at higher odds of having a tattoo placed at index endoscopy. CONCLUSION: Endoscopic tattoo placement and location in relation to the lesion varies widely, with reports containing suboptimal documentation. Lesion location and laparoscopic procedures were significant predictors of tattoo placement. This study highlights the need for standardized tattooing practices and reporting amongst endoscopists. One of the focus of quality improvement efforts should be educational initiatives for rural endoscopists.

The Association Between Wait Times for Colorectal Cancer Treatment and Health Care Costs: A Population-Based Analysis.

BACKGROUND: Health care costs and wait times for colorectal cancer treatment are increasing in Canada, but the association between the 2 remains unclear. OBJECTIVE: This study aimed to determine the association between wait times and health care costs and utilization. DESIGN: This is a population-based retrospective cohort study. SETTING: This study was conducted in Manitoba, Canada. PATIENTS: Patients diagnosed with colorectal cancer between 2004 and 2014 were sorted and ranked into quintiles based on the time from index contact for a colorectal cancer-related symptom to first treatment. MAIN OUTCOME MEASURES: The primary outcome is risk-adjusted health care costs, and the secondary outcomes include health care utilization and overall mortality. RESULTS: We included a total of 6936 patients. Total wait times ranged between 0 and 762 days. In comparison with very short wait times, longer wait times were associated with significantly increased costs (short: mean cost ratio 1.21; 95% CI, 1.10-1.32; moderate: mean cost ratio 1.30; 95% CI, 1.19-1.43; long: mean cost ratio 1.48; 95% CI, 1.33-1.64; and very long: mean cost ratio 1.39; 95% CI, 1.26-1.54). Compared with very short wait times, longer wait times were associated with significantly lower risk of mortality (short: HR, 0.78; 95% CI, 0.71-0.86; moderate: HR, 0.72; 95% CI, 0.65-0.80; long: HR, 0.73; 95% CI, 0.66-0.82; very long: HR, 0.76; 95% CI, 0.68-0.85). The median number of pretreatment radiological and endoscopic investigations and surgeon clinic visits increased over the study period across all wait time categories. LIMITATIONS: This is a nonrandomized, retrospective cohort study with potentially limited generalizability. CONCLUSION: Patients with very short and short wait times are likely those diagnosed with life-threatening complications of colorectal cancer. Outside this window, patients with longer wait times experience increased health care costs and utilization with similar overall mortality. Improved care coordination and patient navigation may help contain the increasing wait times and associated increasing health care costs and utilization. See Video Abstract at http://links.lww.com/DCR/B81. ASOCIACIÓN ENTRE LOS TIEMPOS DE ESPERA PARA EL TRATAMIENTO DE UN CÁNCER COLORRECTAL Y LOS COSTOS DE ATENCIÓN MÉDICA: UN ANÁLISIS DE POBLACIÓN: los costos de atención médica y los tiempos de espera para el tratamiento del cáncer colorrectal están aumentando en Canadá, pero la asociación entre los dos sigue sin estar clara.determinar la asociación entre los tiempos de espera y los costos y la utilización de la atención médicaun estudio de cohorte retrospectivo basado en la población.Manitoba, Canadálos pacientes diagnosticados con cáncer colorrectal entre 2004-2014 se clasificaron y sub-clasificaron en quintiles según el tiempo desde el primer contacto índice de síntomas relacionados con cáncer colorrectal hasta el primer tratamiento.El resultado primario son los costos de atención médica ajustados al riesgo, y los resultados secundarios incluyen la utilización de la atención médica y la mortalidad general.Incluimos un total de 6,936 pacientes. Los tiempos de espera totales oscilaron entre 0-762 días. En comparación con los tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con costos significativamente mayores (Corto: relación de costo promedio 1.21, intervalo de confianza del 95% 1.10-1.32; Moderado: relación de costo promedio 1.30, intervalo de confianza del 95% 1.19-1.43; Largo: media relación de costo 1.48, intervalo de confianza del 95% 1.33-1.64; Muy largo: relación de costo promedio 1.39, intervalo de confianza del 95% 1.26-1.54). En comparación con tiempos de espera muy cortos, los tiempos de espera más largos se asociaron con un riesgo de mortalidad significativamente menor (Corto: razón de riesgo 0.78, intervalo de confianza del 95% 0.71-0.86; Moderado: razón de riesgo 0.72, intervalo de confianza del 95% 0.65-0.80; Largo: peligro cociente 0.73, intervalo de confianza del 95% 0.66-0.82; Muy largo: cociente de riesgos 0.76, intervalo de confianza del 95% 0.68-0.85). La mediana del número de investigaciones radiológicas y endoscópicas previas al tratamiento y las visitas al cirujano aumentaron durante el período de estudio en todas las categorías de tiempo de espera.estudio de cohortes retrospectivo, no aleatorio con generalización potencialmente limitadalos pacientes con tiempos de espera « muy cortos ¼ y « cortos ¼ son probablemente aquellos diagnosticados con complicaciones potencialmente mortales del cáncer colorrectal. Fuera de esta ventana, los pacientes con tiempos de espera más largos experimentan mayores costos de atención médica y utilización con una mortalidad general similar. La coordinación mejorada de la atención y la navegación del paciente pueden ayudar a contener el aumento de los tiempos de espera y el aumento de los costos y la utilización de la atención médica. Consulte Video Resumen en http://links.lww.com/DCR/B81. (Traducción-Dr. Edgar Xavier Delgadillo).

Timing of Palliative Care in Colorectal Cancer Patients: Does It Matter?

BACKGROUND: Palliative care can improve end-of-life care and reduce health care expenditures, but the optimal timing for initiation remains unclear. We sought to characterize the association between timing of palliative care, in-hospital deaths, and health care costs. METHODS: This is a retrospective cohort study including all patients who were diagnosed and died of colorectal cancer between 2004 and 2012 in Manitoba, Canada. The primary exposure was timing of palliative care, defined as no involvement, late involvement (less than 14 d before death), early involvement (14 to 60 d before death), and very early involvement (>60 d before death). The primary outcome was in-hospital deaths and end-of-life health care costs. RESULTS: A total of 1607 patients were included; 315 (20%) received palliative care and 162 (10%) died in hospital. Compared to those who did not receive palliative care, patients with early and very early involvement experienced significantly decreased odds of dying in hospital (OR 0.21 95% CI 0.06-0.69 P = 0.01 and OR 0.11 95% CI 0.01-0.78 P = 0.03, respectively) and significantly lower health care costs. There were no significant differences in in-hospital deaths and health care costs between patients without palliative care and those who received late palliative care. CONCLUSIONS: Early palliative care involvement is associated with decreased odds of dying in hospital and lower health care utilization and costs in patients with colorectal cancer. These findings provide real-world evidence supporting early integration of palliative care, although the optimal timing (early versus very early) remains a matter of debate.

Perspectives From Patients and Care Providers on the Management of Fecal Incontinence: A Needs Assessment.

BACKGROUND: A large proportion of Canadians experience fecal incontinence, with no avenue for effective treatments. The Ottawa Hospital has recently started a percutaneous tibial nerve stimulation program for patients who have not improved with conservative efforts. OBJECTIVE: As part of this program implementation, a qualitative needs assessment was undertaken to better define successful outcomes and to identify barriers for program sustainability. DESIGN: This was a cross-sectional, qualitative study involving standardized, semistructured interviews. SETTINGS: The study was conducted at a single tertiary care center. PATIENTS: Patients experiencing fecal incontinence, as well as nurses, physical therapists, and physicians, were enrolled in the study. MAIN OUTCOME MEASURES: Interview questions revolved around success definitions, barriers, and promoters of fecal incontinence care. Transcripts were analyzed to develop themes surrounding fecal incontinence care. RESULTS: Twelve interviews were undertaken raising a total of 17 different themes. Barriers to fecal incontinence care included education for both the care provider and patients. Access issues for treatments were also highlighted. Promoters of fecal incontinence care were reflected by the impact that it has on quality of life, personal hygiene, psychological burden, and activity and productivity. The definition of fecal incontinence success was focused on improvements in quality of life rather than a numerical reduction of incontinence episodes. LIMITATIONS: This study was limited in its small number of interviews conducted. We were unable to identify patients who were unable to seek out care for fecal incontinence. CONCLUSIONS: Patient and care provider education surrounding fecal incontinence is lacking. Furthermore, access for effective treatments is a real barrier for Canadians experiencing fecal incontinence. Programs should focus on improvement of overall quality of life rather than a reduction of incontinence episodes.