Proposed clinical operative synoptic report for ileocolic resection for Crohn's disease

Crohn's disease patients may require multiple surgeries during their lifetime. Because operative reports are not standardized, information relevant to future management may not be documented. Synoptic reports used in other fields such as histopathology have proven to be effective and allow consistent documentation of results. The aim of this study was to retrospectively review the completeness of the operative reports for ileocolic Crohn's resections (ICR) and to propose a synoptic report.


Background
Patients suffering from Crohn's disease (CD) are likely to undergo multiple surgeries during their lifetime. 1,2The current understanding of the pathogenesis of CD remains incomplete and is likely to be multifactorial.Different aspects of surgery such as the type of anastomosis are thought to have an influence on the recurrence rates of CD following surgery. 3It remains unclear what the ideal anastomosis for ileocolic resections (ICR) for CD. 4 The literature on the outcomes following ICR for Crohn's remains mixed for multiple reasons.Amongst them, poor documentation of the important data set limits the analysis of outcomes.The European Crohn's and Colitis Organization (ECCO) recently published a review urging for optimization of reporting in surgery, endoscopy, and histopathology for inflammatory bowel disease (IBD) patients. 5A study of four centres in the USA and Canada in 2021 reported the significant variability and poor documentation in the operating reports for ICRs across the institutions. 6 clinical operative synoptic report can overcome this deficiency and ensure that all relevant and pertinent information is reported.This was echoed by SNAPCROHN study that recommended intraoperative photographic documentation of CD surgery. 7Similar synoptic reports have been developed and used in the clinical settings such as operative reports for cancers, 8 histopathology for cancers and imaging for rectal cancers. 9They have been shown to improve the quality of the operative reports. 10o the authors' best knowledge, there is no operative synoptic report in the literature for ICR for Crohn's disease currently.
Therefore, the aim of this study is to develop and propose a clinical operative synoptic report for ICR for Crohn's disease.

Methods
Following a literature review, the authors made a draft synoptic report consisting of the sectionsclinical information, disease details and surgical details.This draft was presented in the hospital's IBD multidisciplinary meeting.The individual variable or parameters were discussed and voted on by the consensus panel using a Delphi process.The panel consisted of four colorectal surgeons, five IBD physicians, three IBD specialist nurses, the colorectal fellow and trainee, four gastroenterologist advanced trainees and stomal therapists.The initial draft consisted of a histopathology component, but the consensus panel voted that it should be a separate report.
A retrospective analysis of the hospital's prospective surgical audit database for all consecutive cases of ileocolic resection for Crohn's disease was performed from January 2010 to April 2023.The Crohn's Colitis Care (CCCare) database was also cross-referenced to ensure no patients were missed out.CCCare is a clinical and research cloud-based database that has been used by the IBD team since 2017.Ethics approval was obtained from the Human Research Ethics Application (HREC) (2023/ ETH01252).
The inclusion criteria were: • ≥16 years old • Ileocolic resection performed in Liverpool Hospital during the study period The exclusion criteria were: • <16 years old • Ileocolic resection performed for non-Crohn's pathology • Intestinal-sparing surgery (Michelassi-type anastomosis) for ileocolic Crohn's disease All the electronic operative reports were reviewed for the presence and completeness of the variables/parameters in the proposed clinical operative synoptic report.Completeness was categorized by nil documentation, partial documentation and complete documentation.
The institute has utilized an electronic operative report (Fig. 1) since January 2010.This included the following mandatory fields: date of report, primary surgeon, typist of the report (consultant, fellow, trainee, resident or intern), time of the report typed, and the urgency of the operation (elective vs. emergency).The other parts of the electronic operation report are available as free text.
The clinical details assessed were clinical indication(s) for the surgery, whether primary or secondary operation and the use of induction antibiotics.Primary operation was defined as index surgery and secondary includes any subsequent redo operations.
The operative details assessed were approach to surgery (laparoscopic, laparoscopic-assisted, single incision laparoscopic surgery, robotic or open), reason for conversion to open, severity of adhesions, macroscopic appearance of the small and large intestines, presence of synchronous disease, presence of local involvement of adjacent organs (e.g., sigmoid colon, duodenum, ureter, etc.), extent of mesenteric dissection/resection (pericolic, partial (where feasible), complete), any difficulty encountered and its reason, anastomotic configuration (end-to-end, end-to-side, side-to-side), orientation (antiperistaltic, isoperistaltic), method (stapled or handsewn), other concurrent procedures (e.g., large bowel resection, stricturoplasty), location of extraction of specimen, use of wound protector, use of omental patch, any iatrogenic injury, length of remaining small and large intestines after resection, estimated blood loss, any transfusion of packed red cell, presence and type of stoma and other comments.
Following the data analysis, the results were presented to the IBD multidisciplinary meeting.The synoptic report has been adopted by the group and utilized in prospective cases (Fig. S1).
To analyse and compare for the completeness of the data, eight to ten items were selected: (1) Examination of the macroscopic appearance of the small and large intestines (2) Presence of synchronous disease (3) Extent of mesenteric dissection/resection (pericolic, partial, complete) (4) Any difficulty encountered and its reason (5) Anastomotic configuration (end-to-end, end-to-side, sideto-side) (6) Orientation (antiperistaltic, isoperistaltic) (7) Method (stapled or handsewn) (8) Type of stoma performed (9) Reason for stoma (10) Length of remaining small and large intestines after resection For the patients with an anastomosis and without a stoma, items 8 and 9 were not calculated.Similarly, for the patients that had a stoma without an anastomosis, items 5, 6 and 7 were not calculated.Overall completeness of data was arbitrarily classified as satisfactory (critical items reported greater than or equal to 50%) or excellent (critical items reported greater than or equal to 85%).

Results
During the study period, there were 66 ileocolic resections in 63 patients (including redo surgeries).All the operation reports were electronic.No operation reports were excluded.Figure 2 shows the cases of ICR across the study period.

Clinical information
The compulsory details required for every operative report achieved complete compliance (100%)date of report, primary surgeon, typist of the report (consultant, fellow, trainee, resident or intern), time of the report typed, and the urgency of the operation (elective vs. emergency).
For the clinical indication(s) for the ICR, the report was partially complete in all cases.
Either primary or secondary indication was recorded in 55/66 (83.3%) cases and 8/66 (16.7%) were unclear or not recorded.Only one of the 10 (10%) secondary operations had the prior surgical incision documented.There were five conversions to open procedure and the reasons were all documented.Induction intravenous antibiotics was only documented in 66.7% of cases (44/66).

Disease details
The severity of adhesions was reported in 19.7% (13/66) of cases.The examination of bowel for macroscopic disease of CD was partially complete in 88% of cases.6/66 (9%) had no documentation.The presence or absence of synchronous disease (strictures) was documented in 15/66 (22%) of cases.Similarly, the presence of local involvement of adjacent organs was only available in 7/66 (10.6%) of operation notes.The use of wound protector was documented in 33.3% of cases.

Surgical details
Most of the operation reports (93.9%) had incomplete or nil description of the extent of mesenteric resection for ICR.When assessing for any potential reasons for either complete resection or nil resection of the mesentery in ICR, the majority (87.9%) was not reported.
An anastomosis was performed in 57/66 cases.The description of anastomotic configuration was complete in 53/57 of cases (92.9%) but not described in 7.1% of cases.There were 16 stapled anastomoses, of which 13 were side-to-side anastomoses.Only 7/13 (53.8%) documented anastomotic orientation.Other concurrent resection(s) or stricturoplasty occurred in 33.3% of cases.The remaining cases were presumed not to have any additional procedures.
The location of specimen extraction had 95.5% of complete reporting.The use of an omental patch was reported in one case.
Iatrogenic injury occurred in 3/66 cases.Presumably, there was no iatrogenic injury in the remaining cases and therefore not documented.
The length of remaining small intestine and large intestine was not documented in a large proportion of cases (90.9%).
The estimated blood loss and need of intraoperative transfusion were not documented in any cases.In this study, 14 of the 66 cases required either a diverting (n = 5) or end stoma (n = 9).Only 11/14 had the type of stoma (whether end, loop, loop end, double barrel, or abcarian) described.None of the cases had the reason(s) documented for the formation of a stoma.

Completeness of data
For the patients that underwent primary anastomosis without a stoma, 14/49 (28.6%) of the operation reports achieved satisfactory standards for critical items reported.No operation reports achieved excellence in standards.
For the patients that underwent a primary anastomosis with a diverting stoma, 4/5 (80%) of the operation reports were satisfactory.None achieved excellence in standards.
For the patients that had a stoma without anastomosis, none (n = 9) achieved satisfactory or excellent standards in the operation report.
The sample size was too small to compare between the time of the operation report written and the grade of the typist.

Discussion
Ileocolic CD is the most frequent presenting phenotype.Our study has shown that across a 13-year period at a tertiary referral centre the number of ICRs and reoperations have not increased significantly.This was in keeping with the findings of a large cohort study in Hungary across 3 decades. 11Despite that, the recurrence of CD still challenges the IBD physicians and surgeons in their management. 3Some of the risk factors implicated in recurrence of CD following resection such as the configuration of anastomosis and the preservation or resection of mesentery are poorly documented in the operative notes.This group of patients may require multiple surgeries during their lifetime. 1,2As such, the subsequent treating IBD team may find it challenging to understand what has been performed in the previous operation(s) due to poor documentation.
There has been recent considerable interest in the role of mesentery on the pathogenesis of CD. 12 Naturally, the notion of mesentery preservation or resection raises the question on the recurrence in CD after ICR. 2,13Our study demonstrated that it was poorly documented, which mirrors the findings of Mujukian et al.'s study. 6In our synoptic report, we categorized the extent of mesenteric dissection into pericolic, partial and complete which may better represent the clinical practice as compared with 'high and close'.We included 'any difficulty in mesenteric dissection' to better comprehend the decision made by the surgeon whether it is by choice (as it is a benign disease) or limited by the difficult CD mesentery typically characterized by bulky, thickened, oedematous and friable. 2 We included 'stoma' as part of the synoptic report as a proportion of cases is performed as an emergency for indications of perforations, abscess, and obstructions.This component was not assessed in the Mukujian's study. 6This group of patients is often nutritionally depleted or on high doses of steroids and may not be suitable for primary anastomosis or requires a diverting stoma.An accurate description of the type of stoma will assist subsequent preoperative planning during the reversal of stomawhether contrast imaging-based study or endoscopy assessment is required or feasible to be performed to assess for anastomotic integrity and the remaining colon for any disease activity.
A proportion of patients are diagnosed with CD during their teenage years and the incidence is expected to increase.A Canadian group proposed a medical summary transfer template for transition of IBD care in paediatric patients to the adult IBD team. 14In our study, the remaining length of intestine was completely documented in less than 10% of cases.During the consensus panel's discussion, it was thought that it could be difficult to measure in the minimally invasive cases of the remaining length of small intestine.The length of small and large intestines resected should be at least recorded in the operative report, and whether the remaining length appears to be macroscopically normal.Should the patient move to another hospital/state/country and require further operation, the treating surgeon can be confident preoperatively on the remaining length of intestine.This may have significant implication for the planned procedureresection versus intestinal-sparing procedures.
The anastomotic configuration and orientation did not achieve 100% complete documentation.This could lead to confusion on surveillance imaging scans where the side-to-side functional end-to-end anastomosis may appear 'dilated' raising concerns for obstruction from CD recurrent stricture but in fact it is due to the configuration.
It was surprising to observe that less than one third of operation reports achieve satisfactory standards and none achieved excellence.The substandard operative reports may affect all aspects of future decision-making from administering prophylactic biologics, surveillance colonoscopies to reoperations for recurrences.We initially intended to compare the timing of operative report written but the sample size was too small for any meaningful analysis.The grade of typist was not assessed as well due to the significant bias where operation reports tend to be written by the fellow or trainee registrars.
This study has a few strengths.The operative reports were reviewed by the author who was not involved in the operations eliminating any recall bias.Despite achieving a slightly lower number of cases, the institute still had a relatively high caseload over the last decade.The study has been limited by the exclusion of cases which involved intestinal-sparing approach (Michelassi-type) for ileocolic CD. 15 A few operative details were understandably not documented such as iatrogenic injury if no event was encountered.This was similar to the Mujukian's study. 6The need for intraoperative blood transfusion was the same as it is relatively rare to need blood transfusion in current practice.They are usually a reflection of the difficulty of the procedure.
Certain clinical details that are already inbuilt as part of the electronic operative reports showed 100% compliance of data entry.This strengthens our belief that this synoptic report when used will achieve the same goal.A study that evaluated the motivations and barriers in implementation of a synoptic operative report for rectal cancer surgery found it was easy to implement and incorporate into the workflow. 16The unit has commenced on prospective cases which were easily used without too much additional time and achieved full compliance.The authors' institute is utilizing the CCCare in the clinical management of IBD patients (Fig. 4).Unfortunately, the section on the operative details is often lacking.With this synoptic report, it is hopeful that it will be incorporated into the CCCare soon and the data will be available for future research purposes.
The unit's future aspirations would be to develop similar synoptic reports for other IBD operations that will be acceptable and adopted by the international community for future meaningful analysis of common data language.

Conclusion
In conclusion, the critical operative details in operative reports of ICR for CD are deficient.The proposed synoptic report is easy to use and will overcome any potential for missing documentation.

Fig. 1 .
Fig.1.The electronic operative report utilized in the institute that consists of mandatory fields (highlighted in yellow) and other sections that are available as free text.