Use of Serotonergic Drugs in Canada for Gastrointestinal Motility Disorders: Results of a Retrospective Cohort Study.

Background. Surgery for GI dysmotility is limited to those with severe refractory disease. Though effective, use of serotonergic promotility drugs has been restricted in Canada due to adverse events. We aimed to investigate utilization of promotility serotonergic drugs in patients under consideration for surgical management. Methods. A retrospective cohort study was conducted using prospectively collected data. The study population included consecutive patients referred to a motility clinic for consideration of bowel resection at a Canadian tertiary hospital (1996-2011). Univariable tests and multivariable logistic regression analyses were used to assess predictors of serotonergic drug use. Results. Of 128 patients, the majority (n = 98, 76.6%) had constipation-dominant symptoms. Only 25% (n = 32) had tried serotonergic promotility drugs. There was no association between use of these drugs and severity of constipation nor was there an association between serotonergic drug use and presence of diffuse dysmotility (all p > 0.05). The majority of patients (n = 97, 75.8%) underwent some type of surgical resection, which was associated with considerable morbidity (n = 13, 13.4%). Conclusions. Surgical management of GI dysmotility results in serious morbidity. Serotonergic promotility drugs may allow patients to avoid surgery but disease severity does not predict use of these drugs.

Histological findings in resected bowel of motility-disordered patients.

Gastrointestinal (GI) motility disorders are prevalent conditions associated with pain and bowel dysfunction. Some motility-disordered patients with intractable symptoms have undergone bowel resection aimed at palliating their symptoms. Our objective was to describe a population of motility-disordered patients with histopathological abnormalities identified in full-thickness surgical biopsies. A retrospective cohort study using prospectively collected clinical data and pathology reports was conducted. All adult patients referred to a tertiary motility clinic from 1996 to 2011 who had bowel resection for motility disorder were consecutively sampled. Fisher's exact test was used. Ninety-seven patients were referred for motility disorder during this time and pathology reports were available for 62 patients (63.9%). Hypertrophy or hyperplasia of the myenteric plexus was reported in 13 patients (21.0%). These patients were predominantly females with constipation-dominant symptoms. They were more likely to have objective evidence of colonic inertia (P = 0.01) than patients without myenteric plexus hypertrophy/hyperplasia. Consistent histopathologic abnormalities of myenteric plexus hypertrophy/hyperplasia were described in 21 per cent of patients with refractory GI motility disorders referred for surgical management. Our findings contrast with the hypoganglionosis reported in the slow transit constipation literature. Future studies are needed to systematically investigate these novel histologic findings through a follow-up immunohistochemical study of stored bowel specimens.

Improved health-related quality of life after surgical management of severe refractory constipation-dominant irritable bowel syndrome.

Irritable bowel syndrome (IBS) is the most common of the functional gastrointestinal disorders (FGIDs). Despite its prevalence and health-care costs, there are few effective therapies for patients with severe symptoms. Our objective was to determine whether surgical management would improve health-related quality of life (HRQOL) in severe refractory constipation-dominant FGIDs. From 2003 to 2005, 6 patients underwent total colectomy with end ileostomy or primary anastomosis. They completed Short Form 36 (SF-36) and IBS-36 questionnaires preoperatively and postoperatively. HRQOL was compared with age- and sex-matched Canadian norms using Welch's unpaired t test. Preoperative SF-36 physical and mental health summary scores were significantly lower than Canadian norms (P < 0.0001), while postoperative scores were not significantly different than Canadian norms (P = 0.50 and P = 0.57, respectively). After surgical management, HRQOL in patients with severe constipation-dominant IBS improved from drastically below that of Canadian norms to a comparable level. This finding questions the convention of avoiding operations in IBS patients and demonstrates that surgical management may be suitable for the appropriately screened patient.

Technical skills assessment toolbox: a review using the unitary framework of validity.

OBJECTIVE: The purpose of this study was to create a technical skills assessment toolbox for 35 basic and advanced skills/procedures that comprise the American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) surgical skills curriculum and to provide a critical appraisal of the included tools, using contemporary framework of validity. BACKGROUND: Competency-based training has become the predominant model in surgical education and assessment of performance is an essential component. Assessment methods must produce valid results to accurately determine the level of competency. METHODS: A search was performed, using PubMed and Google Scholar, to identify tools that have been developed for assessment of the targeted technical skills. RESULTS: A total of 23 assessment tools for the 35 ACS/APDS skills modules were identified. Some tools, such as Operative Performance Rating System (OSATS) and Objective Structured Assessment of Technical Skill (OPRS), have been tested for more than 1 procedure. Therefore, 30 modules had at least 1 assessment tool, with some common surgical procedures being addressed by several tools. Five modules had none. Only 3 studies used Messick's framework to design their validity studies. The remaining studies used an outdated framework on the basis of "types of validity." When analyzed using the contemporary framework, few of these studies demonstrated validity for content, internal structure, and relationship to other variables. CONCLUSIONS: This study provides an assessment toolbox for common surgical skills/procedures. Our review shows that few authors have used the contemporary unitary concept of validity for development of their assessment tools. As we progress toward competency-based training, future studies should provide evidence for various sources of validity using the contemporary framework.