Objective To prospectively assess the construct and criterion validity of ClassIntra version 1.0, a newly developed classification for assessing intraoperative adverse events. Design International, multicentre cohort study. Setting 18 secondary and tertiary centres from 12 countries in Europe, Oceania, and North America. Participants The cohort study included a representative sample of 2520 patients in hospital having any type of surgery, followed up until discharge. A follow-up to assess mortality at 30 days was performed in 2372 patients (94%). A survey was sent to a representative sample of 163 surgeons and anaesthetists from participating centres. Main outcome measures Intraoperative complications were assessed according to ClassIntra. Postoperative complications were assessed daily until discharge from hospital with the Clavien-Dindo classification. The primary endpoint was construct validity by investigating the risk adjusted association between the most severe intraoperative and postoperative complications, measured in a multivariable hierarchical proportional odds model. For criterion validity, inter-rater reliability was evaluated in a survey of 10 fictitious case scenarios describing intraoperative complications. Results Of 2520 patients enrolled, 610 (24%) experienced at least one intraoperative adverse event and 838 (33%) at least one postoperative complication. Multivariable analysis showed a gradual increase in risk for a more severe postoperative complication with increasing grade of ClassIntra: ClassIntra grade I versus grade 0, odds ratio 0.99 (95% confidence interval 0.69 to 1.42); grade II versus grade 0, 1.39 (0.97 to 2.00); grade III versus grade 0, 2.62 (1.31 to 5.26); and grade IV versus grade 0, 3.81 (1.19 to 12.2). ClassIntra showed high criterion validity with an intraclass correlation coefficient of 0.76 (95% confidence interval 0.59 to 0.91) in the survey (response rate 83%). Conclusions ClassIntra is the first prospectively validated classification for assessing intraoperative adverse events in a standardised way, linking them to postoperative complications with the well established Clavien-Dindo classification. ClassIntra can be incorporated into routine practice in perioperative surgical safety checklists, or used as a monitoring and outcome reporting tool for different surgical disciplines. Future studies should investigate whether the tool is useful to stratify patients to the appropriate postoperative care, to enhance the quality of surgical interventions, and to improve long term outcomes of surgical patients. Trial registration ClinicalTrials.gov NCT03009929 .

This brief discusses the definition of nominal group technique; how to prepare for it; the four-step process to conduct it; when to use it; and the disadvantages and advantages of its use.

Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.

BACKGROUND: Prolonged postoperative ileus is a common major complication after abdominal surgery. Retrospective data suggest that ileus doubles the cost of inpatient stay. However, current economic impact data are based on retrospective studies that rely on clinical coding to diagnose ileus. OBJECTIVE: The aim of this study was to determine the economic burden of ileus for patients undergoing elective colorectal surgery. DESIGN: Economic data were audited from a prospective database of patients who underwent surgery at Auckland City Hospital between September 2012 and June 2014. SETTINGS: Auckland City Hospital is a large tertiary referral center, using an enhanced recovery after surgery protocol. PATIENTS: Patients were prospectively diagnosed with prolonged postoperative ileus using a standardized definition. MAIN OUTCOME MEASURES: The cost of inpatient stay was analyzed with regard to patient demographics and operative and postoperative factors. A multivariate analysis was performed to determine the cost of ileus when accounting for other significant covariates. RESULTS: Economic data were attained from 325 patients, and 88 patients (27%) developed ileus. The median inpatient cost (New Zealand dollars) for patients with prolonged ileus, including complication rates and length of stay, was $27,981 (interquartile range= $20,198 to $42,174) compared with $16,317 (interquartile range = $10,620 to $23,722) for other patients, a 71% increase in cost (p < 0.005). Ileus increased all associated healthcare costs, including medical/nursing care, radiology, medication, laboratory costs, and allied health (p < 0.05). Multivariate analysis showed that ileus remained a significant financial burden (p < 0.005) when considering rates of major complications and length of stay. LIMITATIONS: This is a single-institution study, which may impact the generalizability of our results. CONCLUSIONS: Prolonged ileus causes a substantial financial burden on the healthcare system, in addition to greater complication rates and length of stay in these patients. This is the first study to assess the financial impact of prolonged ileus, diagnosed prospectively using a standardized definition. See Video Abstract at http://links.lww.com/DCR/A825.

Aim Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. Method This international patient–provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS. Results Three hundred twenty‐five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. Conclusion This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

BackgroundDespite considerable efforts to address practical barriers, colorectal cancer screening numbers are often low. People do not always act rationally, and investigating emotions may offer insight into the avoidance of screening. The current work assessed whether fear, embarrassment, and disgust predicted colorectal cancer screening avoidance.MethodsA community sample (N = 306) aged 45+ completed a questionnaire assessing colorectal cancer screening history and the extent that perceptions of cancer risk, colorectal cancer knowledge, doctor discussions, and a specifically developed scale, the Emotional Barriers to Bowel Screening (EBBS), were associated with previous screening behaviours and anticipated bowel health decision-making.ResultsStep-wise logistic regression models revealed that a decision to delay seeking healthcare in the hypothetical presence of bowel symptoms was less likely in people who had discussed risk with their doctor, whereas greater colorectal cancer knowledge and greater fear of a negative outcome predicted greater likelihood of delay. Having previously provided a faecal sample was predicted by discussions about risk with a doctor, older age, and greater embarrassment, whereas perceptions of lower risk predicted a lower likelihood. Likewise, greater insertion disgust predicted a lower likelihood of having had an invasive bowel screening test in the previous 5 years.ConclusionsAlongside medical and demographic factors, fear, embarrassment and disgust are worthy of consideration in colorectal cancer screening. Understanding how specific emotions impact screening decisions and behaviour is an important direction for future work and has potential to inform screening development and communications in bowel health.

BACKGROUND & AIMS: Antibiotic treatment is the standard care for patients with uncomplicated acute diverticulitis. However, this practice is based on low-level evidence and has been challenged by findings from 2 randomized trials, which did not include a placebo group. We investigated the non-inferiority of placebo vs antibiotic treatment for the management of uncomplicated acute diverticulitis. METHODS: In the selective treatment with antibiotics for non-complicated diverticulitis study, 180 patients hospitalized for uncomplicated acute diverticulitis (determined by computed tomography, Hinchey 1a grade) from New Zealand and Australia were randomly assigned to groups given antibiotics (n [ 85) or placebo (n [ 95) for 7 days. We collected demographic, clinical, and laboratory data and answers to questionnaires completed every 12 hrs for the first 48 hrs and then daily until hospital discharge. The primary endpoint was length of hospital stay; secondary endpoints included occurrence of adverse events, readmission to the hospital, procedural intervention, change in serum markers of inflammation, and patient-reported pain scores at 12 and 24 hrs. RESULTS: There was no significant difference in median time of hospital stay between the antibiotic group (40.0 hrs; 95% CI, 24.4-57.6 hrs) and the placebo group (45.8 hrs; 95% CI, 26.5-60.2 hrs) (P [ .2). There were no significant differences between groups in adverse events (12% for both groups; P [ 1.0), readmission to the hospital within 1 week (1% for the placebo group vs 6% for the antibiotic group; P [ .1), and readmission to the hospital within 30 days (11% for the placebo group vs 6% for the antibiotic group; P [ .3). CONCLUSIONS: Foregoing antibiotic treatment did not prolong length of hospital admission. This result provides strong evidence for omission of antibiotics for selected patients with uncomplicated acute diverticulitis. ACTRN: 12615000249550.

Serious complications can occur following mobilization of the rectum for cancer including: ureteric injury, rectal perforation, hemorrhage, autonomic nerve damage, and local recurrence of the tumor in the pelvis. Each of these complications can be minimized by careful dissection in correct tissue planes in the pelvis. The rectum and mesorectum are surrounded by the fascia propria, a thin fascial envelope. This envelope offers a surface for dissection that leads the surgeon to a safe plane lying inside the autonomic nerves, the ureter, and the presacral vessels, and lying outside of the mesorectum and its associated vessels and lymphatics. The surgical anatomy of the pelvis is presented, with emphasis on the rectal fascia propria, as a basis for a detailed description of the technique of extrafascial excision of the rectum. Semin. Surg. Oncol. 18:207–215, 2000. © 2000 Wiley‐Liss, Inc.