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2013 Podium Awards


2013 1st Podium Award

APPLICATION INFORMATION:

Establishment of a novel standardized electronic framework for interdisciplinary management and monitoring of patient care pathways in Crohn’s disease.

Traa, MX

Tufts Medical Center

Department of Colon and Rectal Surgery

800 Washington Street

Boston, MA 02111

Corresponding author: mtraa@tuftsmedicalcenter.org

ABSTRACT:

Establishment of a novel standardized electronic framework for interdisciplinary management and monitoring of patient care pathways in Crohn’s disease.

Traa, MX

Background: Management of patients with Crohn’s disease represents a significant challenge. The long-term and highly heterogeneous clinical course mandates an interdisciplinary approach involving multiple professionals and institutions. On this background, establishing a standardized data framework for collecting clinical symptoms, interventions, and long-term outcomes can have significant implications on facilitating direct care, service monitoring and epidemiological research.

Aims: We sought to develop a robust electronic registry system for documentation of Crohn’s patient care pathways that could be used for the purposes of research and real-time clinical care.

Methods: Workflow stages, outcome codes and data fields were systematically designed by an iterative process of consultation, trial and feedback within the colorectal surgery department to accurately reflect the various stages of the care pathway. Diagnostic codes were adapted from the ICD-10 international coding system. A retrospective chart review was conducted to input the clinical information for a total of 80 patients with Crohn’s disease at Tufts Medical Center between May 2009 and April 2013.

Results: An electronic database was designed to record and retrieve chronologic information regarding clinical encounters (emergency department, clinic, or operative), investigations (radiological or endoscopic), and resultant diagnoses. Healthcare providers entered data points easily via desktop or tablet computer to document care by the colorectal surgeon or the multidisciplinary team. This data could be rapidly and easily mined by electronic query for information regarding any part of the recorded pathway of care.

Conclusions: This systematic electronic database records critical diagnostic and therapeutic steps in multidisciplinary care pathways for patients with Crohn’s disease. Uniquely, it preserves their temporal relationship to allow more valid analysis of cause and effect relationships compared to classical databases. Its user-friendly platform and accessibility from any World Wide Web enabled device can facilitate both research and real-time clinical use. Excitingly, it offers the possibility for development as a common dataset or registry allowing data sharing with an inter-departmental and inter-institutional scope.


2013 2st Podium Award

Does Entereg Shorten Length of Stay in Patients Undergoing Laparoscopic Colectomy?

Dan Mullins, Kristina Johnson, Kristy Thurston, Ilene Staff

CT Surgical Group PC, Hartford, CT

Introduction: Alvimopan (entereg) has been shown to decrease the length of hospital stay after open colon resection. However, no prospective randomized double-blinded study has been done to validate its use with laparoscopic colon resection. This study was conducted to determine if entereg reduces length of hospital stay and has an effect on return of gastrointestinal (gi) function on patients following laparoscopic colonic resection enrolled in a fast-track recovery pathway (FRP).

Materials and Methods: Patients undergoing elective laparoscopic intestinal surgery were randomly assigned to receive either alvimopan or placebo during their hospital stay using a double-blind approach. Overall hospital length of stay, calculated times from surgery to first flatus or first bowel movement, and the time needed to ingest a diet sufficient for discharge were recorded and compared using Wilcoxon Ranked Sum tests. A Cox Regression analysis was used to account for potential confounds of gender and ages. The rates of major in-hospital complications, ileus and nasogastric tube insertion, and 30 day re-admission rates were also recorded and compared using Fisher’s Exact test.

Results: 132 patients were included in the study, 69 of which received alvimopan. There was no significant difference in the length of hospital stay (4 days vs. 4 days, p = 0.74), time to flatus (3230 vs. 3081 minutes, p = 0.44), time to first bowel movement (3421 vs. 3162 minutes, p = 0.71), or any gi function (2973 vs. 2899 minutes, p =0.36) amongst the placebo and alvimopan groups, respectively. Only the time until tolerance of a discharge diet (1440 vs. 1621 minutes, p = 0.02) achieved statistical significance. Gender was not shown to have any impact, while increasing age was an independent predictor for delaying gi function (OR = 0.985, p = 0.045). The complication rate (2.9% vs. 4.8%, p = 0.67), rate of ileus and ng tube insertions (2.9 vs. 3.2%, p = 1) or re-admission rate (4.3% vs. 7.9%, p = 0.48) also had no statistical difference amongst the groups.

Conclusion: Alvimopan has not been shown to be an effective means of promoting earlier discharge and gi recovery in patients following laparoscopic colectomy placed on a FRP.


2013 3rd Podium Award

PORTOMESENTERIC VENOUS THROMBOSIS AND INFLAMMATORY BOWEL DISEASE: DOES SURGICAL APROACH MATTER?

AUTHORS Murphy, M. M.1; Irani, J. L.1; Shellito, P. C.2; Bleday, R.1

INSTITUTIONS: 1. Colon and Rectal Surgery , Brigham and Women’s Hospital, Boston, MA, United States.

2. Colon and Rectal Surgery, Massachusetts General Hospital, Boston, MA, United States.

PRESENTER: Melissa Murphy

ABSTRACT BODY:

Purpose : Inflammatory bowel disease (IBD) and laparoscopy have been associated with portomesenteric venous thrombosis (PVT). The relationship between IBD patients undergoing laparoscopic surgery and PVT has not been well defined. The purpose of this study was to determine the incidence of PVT among patients undergoing bowel surgery in a two-institution retrospective review, identify predictive factors, and assess outcomes.

Methods : A retrospective study of all patients undergoing open or laparoscopic bowel surgery from January 2008 to July 2012 was performed. Incidence of PVT was determined by radiologic imaging on CT scan or abdominal US. Patient demographics (age, race, sex, body mass index (BMI)), type of surgery, treatment, and outcomes were recorded.

Results : A total of 724 patients underwent bowel surgery (n=458 open, and n=266 laparoscopic).Incidence of PVT was 12.4% (n=33) for laparoscopic bowel surgery, and 1.8% (n=8) for open bowel surgery (p= < 0.01). Factors suggestive of PVT development included laparoscopic bowel surgery, ulcerative colitis, and total proctoclectomy. No significant differences in short term patient outcomes including morbidity and mortality were identified.

Conclusions : Laparoscopic bowel surgery in IBD patients is associated with an increased incidence of PVT with no difference in patient outcomes. We suspect the etiology of the increased rate of PVT in laparoscopic surgery is decreased mesenteric blood flow secondary to increased abdominal pressure during the procedure. Further work needs to be done to investigate whether IBD patients undergoing laparoscopy would benefit from longer term prophylactic anticoagulation or from intermittent release of pneumoperitoneum.

Authors Address

Melissa Murphy

MM4157

21 Midgley Lane Worcester, MA 01604

mmurphy60@partners.org

Objectives

1.Understand the association between laparoscopy and the development of portomesenteric venous thrombosis

2.Identify the contributing factors to developing portomesenteric venous thrombosis