Post-operative pain after laparoscopic right hemicolectomy for Crohn's disease: a case control study.

AIM: Surgery for Crohn's disease (CD) is characterized by an enhanced inflammatory response. While inflammation can induce hyperalgesia, post-operative pain following surgery for CD has not been characterized. This retrospective study compared a consecutive series of patients undergoing laparoscopic right hemicolectomy for CD and neoplasia performed by a single surgeon. METHOD: Elective resections performed between Jan-2016 and Aug-2017 managed in an enhanced recovery pathway were eligible for inclusion. Patients were excluded if open surgery was performed, an ileostomy was fashioned, no patient-controlled analgesia (PCA) was used or data were incomplete. Results : 38 cases were included, 20 for neoplasia and 18 for ileocolonic CD. There was no difference in patient gender (P=0.520). CD patients were younger (39.8±2.8 Vs 77.2±2.1 years, P<0.001) but had an equivalent length of resection (312.9±43.5 Vs 283.3±71.7 mm, P=0.915). CD patients had higher pain scores on post-operative day 1 (6.8±0.8 Vs 2.6±1.0, P<0.001), day 2 (5.0±0.5 Vs 1.6±0.9, P<0.001) and day 3 (4.1±0.6 Vs 1.3±0.7, P=0.008). CD patients used their PCA for longer (85.7±16.3 Vs 47.7±4.2 hours, P=0.017) and used a greater total amount of morphine (148.6±33.8 Vs 37.0±7.8 mg, P<0.001). Post-operative CRP was higher in patients with CD on day 1 (P=0.011), day 2 (P=0.001), day 3 (P=0.001) and day 4 (P=0.007), but no leak or intra-abdominal abscess occurred in either group. RESULTS: 38 cases were included, 20 for neoplasia and 18 for ileocolonic CD. There was no difference in patient gender (P=0.520). CD patients were younger (39.8±2.8 Vs 77.2±2.1 years, P<0.001) but had an equivalent length of resection (312.9±43.5 Vs 283.3±71.7 mm, P=0.915). CD patients had higher pain scores on post-operative day 1 (6.8±0.8 Vs 2.6±1.0, P<0.001), day 2 (5.0±0.5 Vs 1.6±0.9, P<0.001) and day 3 (4.1±0.6 Vs 1.3±0.7, P=0.008). CD patients used their PCA for longer (85.7±16.3 Vs 47.7±4.2 hours, P=0.017) and used a greater total amount of morphine (148.6±33.8 Vs 37.0±7.8 mg, P<0.001). Post-operative CRP was higher in patients with CD on day 1 (P=0.011), day 2 (P=0.001), day 3 (P=0.001) and day 4 (P=0.007), but no leak or intra-abdominal abscess occurred in either group. CONCLUSIONS: CD patients experience increased post-operative pain, require more post-operative analgesia and have an enhanced post-operative inflammatory response. Further studies to elucidate the mechanism of this hyperalgesia and strategies to obviate it are required.

"Bending the cost curve" in gastroenterology.

INTRODUCTION: Increasing attention is being focused on reigning in escalating costs of healthcare, i.e. trying to 'bend the cost curve'. In gastroenterology (GI), inpatient hospital care represents a major component of overall costs. This study aimed to characterize the trend in cost of care for GI-related hospitalizations in recent years and to identify the most costly diagnostic groups. METHODS: All hospital inpatients admitted between January 2008 and December 2009 with a primary diagnosis of one of the six most common GI-related Diagnosis Related Groups (DRGs) in this hospital system were identified; all DRGs contained at least 40 patients during the study period. Patient Level Costing (PLC) was used to express the total cost of hospital care for each patient; PLC comprised a weighted daily bed cost plus cost of all medical services provided (e.g., radiology, pathology tests) calculated according to an activity-based costing approach; cost of medications were excluded. All costs were discounted to 2009 values. Mean length of stay (LOS) was also calculated for each DRG. RESULTS: Over 2 years, 470 patients were admitted with one of the six most common GI DRGs. Mean cost of care increased from 2008 to 2009 for all six DRGs with the steepest increases seen in 'GI hemorrhage (non-complex)' (31 % increase) and 'Cirrhosis/Alcoholic hepatitis (non-complex)' (45 % increase). No differences in readmission rates were observed over time. There was a strong correlation between year-to-year change in costs and change in mean LOS, r = 0.93. CONCLUSION: The cost of GI-related inpatient care appears to be increasing in recent years with the steepest increases observed in non-complex GI hemorrhage and non-complex Cirrhosis/Alcoholic hepatitis. Efforts to control the increasing costs should focus on these diagnostic categories.

Does the cost of care differ for patients with fee-for-service vs. capitation of payment? A case-control study in gastroenterology.

INTRODUCTION: There is growing evidence to demonstrate overuse of medical resources in fee for service (FFS) payment models (in which physicians are reimbursed according to volume of care provided) compared to capitation payment models (in which physicians receive a fixed salary regardless of level of care provided). In this medical centre, patients with and without insurance are admitted through the same access point (emergency room) and cared for by the same physicians. Therefore, apart from insurance status, all other variables influencing delivery of care are similar for both patient groups. However, physician reimbursement differs for both groups: FFS for patients with private insurance (i.e. the admitting physician's reimbursement escalates progressively with each day that the patient spends in hospital) and base salary irrespective of care provided for patients with universal insurance (capitation payment model). All admitting physicians are aware of the patient's insurance status and the duration of hospitalization is at the discretion of the admitting physician. This study aimed to compare cost of care of patients with and without insurance admitted to a teaching hospital with a primary gastroenterology or hepatology (GIH) diagnosis. METHODS: All hospital inpatients admitted between January 2008 and December 2009 with a primary GI-related diagnosis related group (DRG) were identified. Patients were classified as uninsured (state-funded) or privately insured. Only DRGs with at least five patients in both the insured and uninsured patient groups were analyzed to ensure a precise estimate of inpatient costs. Patient level costing (PLC) was used to express the total cost of hospital care for each patient; PLC comprised a weighted daily bed cost plus cost of all medical services provided (e.g. radiology, pathology tests) calculated according to an activity-based costing approach, cost of medications were excluded. An overall mean cost of care per patient was calculated for both groups. All costs were discounted to 2009 values. RESULTS: In total, 630 patients were admitted with one of 11 GIH DRGs, 181 (29 %) with private insurance. Pooled mean cost of care was higher for uninsured (6,781 euros/patient) compared to insured patients (6,128 euros/patient). Apart from patients with 'non-cirrhotic non-alcoholic liver disease (non-complex)' in whom mean cost was higher for insured patients, there were no significant differences in mean cost of care nor mean patient age for insured and uninsured groups for any other diagnoses. CONCLUSION: Inpatient hospital costs were equivalent for patients with and without private health insurance when care was provided in a single hospital. Provision of care for all patients in a common hospital setting regardless of health insurance status may reduce disparities in healthcare utilization.

Evaluating the clinical efficacy and cost effectiveness of direct access endoscopy.

INTRODUCTION: Direct access endoscopy (DAE) allows primary care physicians (PCPs) to refer patients with concerning symptoms for endoscopy in a timely manner. Guidelines are available to assist PCPs in appropriately selecting patients for DAE. The objective of this study was to evaluate both the clinical benefit and cost effectiveness of an upper gastrointestinal (UGI) DAE program. METHODS: The diagnostic yield of DAE patients attending for UGI studies was evaluated using a prospectively maintained database from 2004 to 2011. The diagnosis of UGI neoplasia, Barretts oesophagus, peptic ulcer disease or other conditions were recorded. In addition the age of the patient and the indication for the UGI endoscopy as per the PCP was compared with National Institute of Clinical Excellence (NICE) guidelines for UGI endoscopy. RESULTS: PCPs referred 4262 patients for UGI endoscopy. Oesophageal cancer was diagnosed in 7 and gastric cancer was identified in 27 patients. This represents a diagnostic yield overall of 0.8% for UGI cancers. Barretts oesophagus was identified in 148 (3.5%) and 185 patients (4.34%) were diagnosed with peptic ulcer disease. Interestingly, 3734 patients (87.6%) had a normal UGI endoscopy through our DAE program representing a cost of 2,296,410 Euro. In patients under 40 years of age the diagnostic yield for UGI cancer was 0.14%. More importantly, 92.2% of UGI endoscopies in patients less 40 years of age were normal. CONCLUSION: It is essential that PCPs adhere to published guidelines prior to referring patients to the DAE program. Furthermore, patients under 40 years of age may represent a subset of patients that may not benefit from immediate UGI endoscopy through a direct access program.

Randomized controlled trial of feedback on cost of hospital care among gastroenterology inpatients.

INTRODUCTION: Spending on hospital inpatients comprises a major proportion of healthcare costs. This study assessed the impact of systematic feedback to gastroenterologists on the cost of care provided to inpatients on a gastrointestinal/hepatology (GIH) hospital service. METHODS: Patients with a GIH diagnosis were randomly assigned to be cared for by one of two hospital services. Over 3 months, teams were randomized to receive feedback (GIH A) or no feedback (GIH B, control group); feedback consisted of an email sent twice weekly to all physicians on the GIH A service detailing the length of stay (LOS) and real-time cost of care accrued by each inpatient. RESULTS: Over 3 months, care was provided to 56 (GIH A) and 47 (GIH B) inpatients with a GIH illness. Patient complexity level was similar for both services as demonstrated by mean relative value: 1.11 (GIH A) vs. 1.27 (GIH B), p=0.2. Weighted LOS and weighted cost of care values were calculated to adjust for the respective RV of each patient. Mean weighted LOS (10.8 [GIH A] vs. 13.8 days/pt [GIH B], p=0.02) and mean weighted cost of care (9,904 [GIH A] vs. 12,654 euros/pt [GIH B], p=0.02) were significantly lower in the feedback group. Subsequent hospital readmission rates did not differ among both groups. CONCLUSION: Systematic feedback on cost of care was associated with lower healthcare costs without compromising quality. Incorporating a running total of patient costs into computer software used to order patient tests may represent one approach to controlling healthcare expenses.

Laparoscopic Nissen fundoplication post-oesophageal stenting: an unusual case.

Laparoscopic Nissen fundoplication post-oesophageal stenting is uncommon and yet to be reported. We report the case of a 57-year-old palliative lady who underwent surgery for symptomatic relief of severe gastrooesophageal reflux post-oesophageal stenting. Surgery was carried out successfully with no complications. On the evening post-surgery she was able to lie supine for the first time in months without symptoms of reflux. In conclusion, surgery is still valuable and may play an important role, even in a palliative setting.

Color matrix refractive index sensors using coupled vertical silicon nanowire arrays.

Vivid colors are demonstrated in silicon nanowires with diameters ranging from 105 to 346 nm. The nanowires are vertically arranged in a square lattice with a pitch of 400 nm and are electromagnetically coupled to each other, resulting in frequency-dependent reflection spectra. Since the coupling is dependent on the refractive index of the medium surrounding the nanowires, the arrays can be used for sensing. A simple sensor is demonstrated by observing the change in the reflected color with changing refractive index of the surrounding medium. A refractive index resolution of 5 × 10(-5) is achieved by analyzing bright-field images captured with an optical microscope equipped with a charge coupled device camera.

Intra-aortic mural thrombosis and splenic infarction in association with ulcerative colitis.

BACKGROUND: Arterial thrombosis is a very rare, but recognised complication of inflammatory bowel disease that can result in significant morbidity and mortality. CASE PRESENTATION: We present the case of a 48-year-old female with previously well-controlled ulcerative colitis who presented with severe left upper quadrant abdominal pain. Imaging investigations subsequently revealed a large intra-aortic mural thrombus extending into the coeliac axis complicated by splenic infarction. This occurred in the absence of other prothrombotic states such as thrombophilias or vasculitis. CONCLUSION: This case highlights the frequently overlooked association between inflammatory bowel disease and arterial thrombosis.

Towards continuous improvement of endoscopy standards: validation of a colonoscopy assessment form.

AIM: The assessment of procedural colonoscopy skills is important and topical. The aim of this study was to develop and validate a competency-based colonoscopy assessment form that would be easy to use, suitable for the assessment of junior and senior endoscopists and potentially a useful instrument to detect differences in performance standards following different training interventions. METHOD: A standardized assessment form was developed incorporating a checklist with dichotomous yes/no responses and a global assessment section incorporating several different elements. This form was used prospectively to evaluate colonoscopy cases during the period of the study in several university teaching hospitals. Results were analysed using ANOVA with Bonferroni corrections for post hoc analysis. RESULTS: Eighty-one procedures were assessed, performed by eight consultant and 19 trainee endoscopists. There were no serious errors. When divided into three groups based on previous experience (novice, intermediate and expert) the assessment form demonstrated statistically significant differences between all three groups (P<0.05). When separate elements were taken into account, the global assessment section was a better discriminator of skill level than the checklist. CONCLUSION: This form is a valid, easy-to-use assessment method. We intend to use it to assess the value of simulator training in trainee endoscopists. It also has the potential to be a useful training tool when feedback is given to the trainee.

Quality of colonoscopy performance among gastroenterology and surgical trainees: a need for common training standards for all trainees?

BACKGROUND AND STUDY AIM: Cecal intubation and polyp detection rates are objective measures of colonoscopy performance. Minimum cecal intubation rates greater than 90% have been endorsed by the American Society for Gastrointestinal Endoscopy (ASGE) and the Joint Advisory Group (JAG) UK. Performance data for medical and surgical trainee endoscopists are limited, and we used endoscopy quality parameters to compare these two groups. METHODS: Retrospective review of all single-endoscopist colonoscopies done by gastroenterology and surgical trainees ("registrars," equivalent to fellows, postgraduate year 5) with more than two years' endoscopy experience, in 2006 and 2007 at a single academic medical center. Completion rates and polyp detection rates for endoscopists performing more than 50 colonoscopies during the study period were audited. Colonoscopy withdrawal time was prospectively observed in a representative subset of 140 patients. RESULTS: Among 3079 audited single-endoscopist colonoscopies, seven gastroenterology trainees performed 1998 procedures and six surgery trainees performed 1081. The crude completion rate was 82%, 84% for gastroenterology trainees and 78% for surgery trainees (P < 0.0001). Adjusted for poor bowel preparation quality and obstructing lesions, the completion rate was 89%; 93% for gastroenterology trainees, and 84% for surgical trainees (P < 0.0001). The polyp detection rate was 19% overall, with 21% and 14% for gastroenterology and surgical trainees, respectively (P < 0.0001). The adenoma detection rate in patients over 50 was 12%; gastroenterology trainees 14% and surgical trainees 9% (P = 0.0065). In the prospectively audited procedures, median withdrawal time was greater in the gastroenterology trainee group and polyp detection rates correlated closely with withdrawal time (r = 0.99). CONCLUSION: The observed disparity in endoscopic performance between surgical and gastroenterology trainees suggests the need for a combined or unitary approach to endoscopy training for specialist medical and surgical trainees.

Utilization of resource leveling to optimize ERCP efficiency.

BACKGROUND: Optimizing endoscopy efficiency is becoming increasingly important. This study profiled ERCP availability and assessed resource leveling as a strategy to enhance efficiency. DESIGN: All ERCPs performed at an academic teaching hospital between January 2007 and December 2008 were reviewed. Procedure timeliness (time between admission and ERCP) and demand were analyzed to assess resource utilization. RESULTS: Data were recorded for 393 ERCPs. Profiling identified an unequal distribution of waiting times from admission to procedure due to restricted ERCP availability. Use of resource leveling methodology demonstrated that a small increase in procedure availability (one additional half day per week) would significantly reduce the hospital stay of ERCP patients. CONCLUSIONS: Resource leveling can be applied to balance procedure provision with demand to cope with fluctuations in demand. The impact of resource leveling can be truly measured only by implementing these changes and prospectively studying the effect.

Potential impact of enhanced practice efficiency on endoscopy waiting times.

BACKGROUND: With the growing demand on endoscopy services, optimising practice efficiency has assumed increasing importance. Prior research has identified practice changes, which increase the efficiency in endoscopy. In this study, the potential impact of these practice changes on the current and projected future endoscopy waiting times at our institution was assessed. METHODS: The annual volume of endoscopic procedures performed at a major teaching hospital and the annual procedure demand from 2000 to 2007 were reviewed. Procedure demand and waiting times were projected until 2012. The impact of three practice changes, which have been shown to increase efficiency was assessed: 1. routinely obtaining i.v. access and consent in patients prior to endoscopy (approach 1); 2. routinely obtaining i.v. access and consent, and sedating the patient prior to endoscopy (approach 2); 3. utilizing a two-room per endoscopist model (approach 3). RESULTS: There has been a significant increase in annual procedure volume (36%) and annual procedure demand (69%) from 2000 to 2007. Annual waiting times for routine procedures have lengthened, from 6 weeks (2000) to 22 weeks (2007). Assuming continued linear growth in demand up to 2012, the projected waiting times will continue to rise reaching 40 weeks in 2012. Routinely obtaining i.v. access/consent prior to procedure (approach 1) would shorten the average routine waiting times so that 8 weeks (recommended HSE maximum) would not be exceeded until early 2006; routinely obtaining i.v. access/consent and sedating patient prior to procedure (approach 2) would shorten the average routine waiting time so that 8 weeks would not be exceeded until 2008; utilising two rooms per endoscopist (approach 3) would shorten the average routine waiting time so that 8 weeks would not be exceeded until early 2012. CONCLUSIONS: Maintaining timely access to endoscopic services is becoming more challenging in the face of growing demand. Modifications in routine clinical practice can significantly impact procedure waiting times. In an era where economic aspects of medical care are becoming increasingly important and where there is growing focus on waiting times as a measure of clinical performance, these findings underscore the importance of providing clinical care in the most efficient manner possible.

Assessment of colorectal cancer knowledge and patient attitudes towards screening: is Ireland ready to embrace colon cancer screening?

INTRODUCTION: The level of awareness among the Irish public regarding colorectal cancer (CRC) remains uncertain. This study aimed to characterise CRC knowledge levels among a cohort of Irish patients. METHODS: A survey evaluating CRC knowledge levels was distributed among outpatients at a gastroenterology clinic in a Dublin teaching hospital. RESULTS: In total, 472 surveys were distributed of which 465 (98.5%) were returned. Twenty-nine percent of respondents correctly judged CRC to be the commonest cause of cancer death among the options provided while 26% correctly judged the lifetime risk of CRC; 59% underestimated and 15% overestimated the risk. Most patients (91%) were willing to pay 300 euros for a prompt colonoscopy if recommended by their physician while 7% opted to wait 6 months for a free colonoscopy. CONCLUSIONS: There is a willingness to embrace CRC screening and to shoulder some of the financial burden that this entails.

Assessment of adherence to published surveillance guidelines--opportunity to enhance efficiency of endoscopic practice.

Strict adherence to recommended surveillance intervals is important in ensuring timely access for patients awaiting endoscopy. This study aimed to characterise adherence rates to surveillance endoscopy guidelines. All surveillance procedures scheduled between January and December 2006 were reviewed. Surveillance procedures were classified as: a) Barrett's oesophagus, b) chronic IBD, c) prior adenomatous colorectal polyps and, d) prior surgical resection of colorectal cancer. 441 endoscopies were scheduled for surveillance of which 195 (44.2%) were scheduled at an inappropriate interval; all were scheduled prematurely. Of these, 50 of 133 (37.6%) Barrett's patients, 92 of 213 (43.2%) patients with prior colonic polyps, 36 of 48 (75.0%) patients with prior colonic malignancy and 17 of 47 (36.2%) patients for IBD surveillance were scheduled prematurely. Almost half of all surveillance procedures were scheduled inappropriately early. This 'over-surveillance' represents an unnecessary additional burden on the current endoscopic workload.

Evaluation of formal feedback on endoscopic competence among trainees: the EFFECT trial.

INTRODUCTION: The medical literature describes disparity in colonoscopy performance. This randomised, controlled study aimed to characterise the impact of feedback on colonoscopy performance among gastroenterology (GI) trainees. METHODS: Gastroenterology trainees of similar experience levels who independently performed 581 colonoscopies over the study period were randomised to receive feedback/no feedback on their colonoscopy performance. RESULTS: Baseline colonoscopy performance was similar in both groups. Following feedback, caecal intubation improved by 10.5% (from 72.9 to 83.4%, p = 0.04) in the feedback group and declined by 6.1% (from 78 to 71.9%, p = 0.2) in the control group; polyp detection improved by 5.1% (from 12.9 to 18.0%, p = 0.2) in the feedback group and by 2.9% (from 16.7 to 19.6%, p = 0.5) in the control group. CONCLUSIONS: Systematic feedback appears to enhance colonoscopy performance among GI trainees.

Mycobacterium marinum infection complicating Crohn's disease, treated with infliximab.

Tumour necrosis factor-alpha inhibitors including infliximab are often used to treat a number of recalcitrant medical conditions. These agents are increasingly associated with infections, particularly mycobacterial infections. We report sporotrichoid spread of Mycobacterium marinum in a 37-year-old woman with Crohn's disease, who had been receiving infliximab infusions for 2 years. An infection had spread up the right leg, after she had been swimming on holiday in the Canary Islands. M. marinum was cultured from the lesions and also identified by PCR on formalin-fixed tissue. To our knowledge, this is the first report of M. marinum occurring in a patient receiving infliximab.

Leg bone pain syndrome in a patient with ulcerative colitis treated with cyclosporin.

BACKGROUND: Leg bone pain syndrome is an unusual condition associated with the use of calcineurin antagonists, initially described in patients receiving allograft transplantation. AIM: To describe the first known reported case of leg bone pain syndrome in a patient with ulcerative colitis receiving cyclosporin. RESULTS: Investigations revealed no diagnostic features. Calcium channel blocker was used successfully in the treatment of this condition. CONCLUSION: In the absence of diagnostic investigations, a high index of clinical suspicion is needed to diagnose and successfully manage leg bone pain syndrome. This may prevent further complications such as osteonecrosis that may arise.

Plasmablastic lymphoma presenting as a paravertebral mass in a patient with Crohn's disease after immunosuppressive therapy.

The case of a 32-year-old man with a paravertebral mass and skin nodules, occurring against a background of immunosuppressive therapy for Crohn's disease, is presented. The tumours showed morphological and immunophenotypical features of plasmablastic lymphoma. To our knowledge, this is the first reported case of plasmablastic lymphoma presenting in this location, and also after immunosuppression with infliximab treatment for Crohn's disease.

Direct-vision stenting: the way forward for malignant oesophageal obstruction.

BACKGROUND AND STUDY AIMS: Self-expanding metallic stents now form the mainstay of treatment for palliation of dysphagia in oesophageal cancer. These stents are generally inserted under fluoroscopic guidance. However, both the internal and external marking of the tumour can be inaccurate and time-consuming, and access to fluoroscopic facilities is sometimes limited. We prospectively assessed the use of a method of stent insertion under direct vision without the aid of fluoroscopy. PATIENTS AND METHODS: A total of 50 consecutive patients presenting with obstructive symptoms secondary to inoperable oesophageal cancers were included in the study. We used either the 7-cm or the 11-cm covered Choo stent (MI-Tech Ltd., Seoul, South Korea). RESULTS: A total of 52 stents were inserted under direct vision. The procedure generally took less than 15 minutes and good palliation was achieved without complications. Fluoroscopic assistance was required in only one patient. CONCLUSIONS: Direct-vision stent insertion is simple, safe, effective, and only rarely requires fluoroscopic assistance. The technique may be of particular use in centres with limited access to fluoroscopy.