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Video Abstract1_yzyy8ep3Kaltura

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.

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.

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.

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.

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Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection. Prospectively collected data entered in a registry specifically designed for ERPs were reviewed. Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements. Primary outcome was successful recovery defined as the absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were length of hospital stay (LOS), 30-day morbidity, and severity (Comprehensive complication index, CCI, 0–100). Regression analyses were adjusted for potential confounders. A total of 347 patients were included in the study. Median primary LOS was 4 days (IQR 3–7). Patients were adherent to median 18 (IQR 16–20) elements. A total of 156 (45 %) patients had successful recovery. Morbidity occurred in 175 (50 %) patients with median CCI 8.6 (IQR 0–22.6). There was a positive association between adherence and successful recovery (OR 1.39 for every additional element, p< 0.001), LOS (11 % reduction for every additional element, p< 0.001), 30-day postoperative morbidity (OR 0.78, p< 0.001), and the CCI (17 % reduction, p< 0.001). Laparoscopy (OR 4.32, p< 0.001), early mobilization out of bed (OR 2.25, p= 0.021), and early termination of IV fluid infusion (OR 2.00, p= 0.013) significantly predicted successful recovery. These factors were also associated with reduced morbidity and complication severity. Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall adherence was high, laparoscopic approach, perioperative fluid management, and patient mobilization remain key elements associated with improved outcomes.