Enhancing communication and reducing the need for repeat preoperative endoscopy between Gastroenterologists and Surgeons, a mixed-methods analysis
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Date
2020
Authors
Hershorn, Olivia
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Abstract
INTRODUCTION: Despite limited endoscopy resources in Canada, repeat preoperative lower endoscopy is commonly practiced. Our aim is to determine repeat preoperative endoscopy rates and factors influencing this practice at a high volume tertiary care centre.
METHODS: A mixed-methods convergent design was undertaken. This included concurrent, but separate, quantitative and qualitative data collection. A retrospective chart review was conducted on all patients undergoing elective colorectal resection for benign and malignant neoplasms between 2007 to 2017. Semi-structured, in-person interviews were conducted with 10 Gastroenterologists and 10 General Surgeons.
RESULTS: Our quantitative analysis identified 1062 patients with a mean age of 68 years and 56% were male. Our repeat preoperative endoscopy rate was 29%. Index endoscopy was performed by a General Surgeon in 53% of cases. A total of 57% of patients underwent tattooing for tumour localization at index endoscopy. Median time to surgery differed amongst those who underwent repeat endoscopy compared to those who did not (159 days versus 64 days). On multivariate analysis, male sex (OR: 1.68, p = 0.003), left colon (OR: 2.73, p = <0.001), rectosigmoid (OR: 9.11, p = 0.003) and rectal lesions (OR: 4.06, p = <0.001) were at increased odds of undergoing repeat endoscopy prior to surgery. Patients with a tattoo placed at index endoscopy were at lower odds of undergoing repeat endoscopy (OR: 0.48, p = <0.001). Predictors of tattoo placement at index endoscopy included lesions located in the transverse colon (OR: 1.93, p = 0.04) and planned laparoscopic surgery (OR: 1.69, p = 0.001). Thematic analysis revealed that communication, feedback, and trust were key themes related to practice patterns and decision-making processes amongst endoscopy physicians.
During physician interviews, variability in tattooing practices and ambiguous documentation was a powerful determinant of repeat preoperative endoscopy. Closed-loop communication, feedback, and joint educational initiatives were proposed to bridge gaps in communication.
CONCLUSIONS: Repeat preoperative endoscopy may be unnecessary if appropriate identification and documentation of lesions has been achieved. Tattooing of suspicious lesions is a modifiable factor associated with reduced likelihood of repeat endoscopy prior to surgery. This study highlights the need for standardization of endoscopic approaches given the delays that repeat preoperative endoscopy is associated with.
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Keywords
Colorectal cancer, Endoscopy, Repeat endoscopy, Endoscopic tattooing