Improving the Quality of Care for patients with Ileocolonic Crohn’s disease undergoing Surgery Improving the Quality of Care for patients with Ileocolonic Crohn’s disease undergoing Surgery Mr Pritesh S Morar MBBS MRCS PgCert (Medical Education) SURGICAL EPIDEMIOLOGICAL TRIALS AND OUTCOMES CENTRE (SETOC) DIVISION OF SURGERY, DEPARTMENT OF SURGERY AND CANCER, IMPERIAL COLLEGE LONDON Thesis towards Doctor of Philosophy (PhD) 2016 Supervisors: Mr Janindra Warusavitarne Professor Omar Faiz Professor Ailsa Hart 1 Improving the Quality of Care for patients with Ileocolonic Crohn’s disease undergoing Surgery CONTENTS ABSTRACT ............................................................................................................................ 17 ACKNOWLEDGEMENTS .................................................................................................. 18 ABBREVIATIONS ................................................................................................................ 19 PUBLICATIONS AND PRESENTATIONS RESULTING FROM THIS THESIS ....... 21 STATEMENT OF CONTRIBUTION AND DECLARATION OF ORIGINALITY ..... 27 THESIS HYPOTHESIS, AIMS AND OBJECTIVES ........................................................ 28 THESIS STRUCTURE ......................................................................................................... 29 CHAPTER 1: INTRODUCTION AND BACKGROUND ................................................. 31 1.1. The Nature of Crohn’s Disease ..................................................................................... 31 1.1.1. History .................................................................................................................... 31 1.1.2. Epidemiology.......................................................................................................... 33 1.1.3. Aetiology ................................................................................................................ 34 1.1.4. The behaviour of Crohn’s Disease ......................................................................... 36 1.1.5. Classification systems: a historical perspective...................................................... 38 1.1.6. The Montreal Classification ................................................................................... 39 1.2. Management strategies .................................................................................................. 39 1.2.1. An overview ........................................................................................................... 39 1.2.2. Medical strategies ................................................................................................... 40 1.2.3. Endoscopic balloon dilatation ................................................................................ 42 1.2.4. Surgical strategies ................................................................................................... 44 2 Improving the Quality of Care for patients with Ileocolonic Crohn’s disease undergoing Surgery 1.3. Surgical outcomes ......................................................................................................... 51 1.3.1. Introduction ............................................................................................................ 51 1.3.2. Short-term outcome measures for small bowel and ileocolonic resection ............. 51 1.3.3. Predictors of intra-abdominal septic complication ................................................. 52 1.3.4. Long term outcome following ileocaecal resection – the recurrent concern .......... 54 1.4. Variability and standards of care ................................................................................... 58 1.4.1. Variability in decision-making ............................................................................... 58 1.4.2. The patient perspective of surgery.......................................................................... 59 1.4.3. The quality of care within an IBD service provision.............................................. 60 1.4.4. The centralisation of care ....................................................................................... 62 1.4.5 Standardising multidisciplinary team driven care ................................................... 63 CHAPTER 2: METHODS AND MATERIALS ................................................................. 65 2.1. Materials ........................................................................................................................ 65 2.1.1. The Crohn’s surgical database ................................................................................ 65 2.1.2. Database screening ................................................................................................. 66 2.1.3. Data extraction ........................................................................................................ 67 2.1.4. Outcome measures .................................................................................................. 68 2.1.5. Data validation ........................................................................................................ 71 2.1.6. Statistical analyses .................................................................................................. 71 2.1.7. Missing data ............................................................................................................ 71 2.2. Qualitative methodology ............................................................................................... 72 3 Improving the Quality of Care for patients with Ileocolonic Crohn’s disease undergoing Surgery 2.2.1. Rationale ................................................................................................................. 72 2.2.2. Semi-structured interviews ..................................................................................... 73 2.3. Achieving consensus through Delphi .......................................................................... 74 CHAPTER 3: THE INSTITUTIONAL INCIDENCE AND PREDICTORS OF INTRA- ABDOMINAL SEPTIC COMPLICATIONS (IASC) FOLLOWING ILEOCOLONIC RESECTION FOR ILEAL CROHN'S DISEASE .............................................................. 76 3.1. Abstract ......................................................................................................................... 76 3.2. Aims .............................................................................................................................. 77 3.3. Methodology ................................................................................................................. 77 3.3.1. Patient selection ...................................................................................................... 77 3.3.2. Outcome measures………………………………………………………………..78 3.3.3. Statistical analysis……………………………………………………………… 79 3.4. Results ........................................................................................................................... 78 3.4.1. Patient and operative demographics ....................................................................... 78 3.4.2. The incidence of IASCs and subsequent management ........................................... 79 3.4.3. One-stage procedures ............................................................................................. 82 3.4.4. Two-stage procedures ............................................................................................. 89 3.5. Discussion ..................................................................................................................... 90 3.5.1. Summary of findings .............................................................................................. 90 3.5.2. Limitations .............................................................................................................. 91 4 Improving the Quality of Care for patients with Ileocolonic Crohn’s disease undergoing Surgery CHAPTER 4: THE INSTITUTIONAL INCIDENCE AND PREDICTORS OF POST- OPERATIVE CLINICAL RECURRENCE FOLLOWING ILEOCOLONIC RESECTION FOR ILEAL CROHN'S DISEASE .............................................................. 92 4.1 Abstract .......................................................................................................................... 92 4.2. Aims .............................................................................................................................. 93 4.3. Methodology ................................................................................................................. 93 4.3.1. Patient selection ...................................................................................................... 93 4.3.2. Outcome measures .................................................................................................. 94 4.3.3. Statistical analysis................................................................................................... 94 4.4. Results ........................................................................................................................... 95 4.4.1. Patient and operative demographics ....................................................................... 95 4.4.2. The incidence of clinical recurrence ....................................................................... 97 4.4.3. Pre-operative factors ............................................................................................... 99 4.4.4. Peri-operative factors