Quality indicators for operative reporting in transanal endoscopic surgery

The operative report is a cornerstone of surgical communication. Historically these reports took the form of a dictated narrative description. Meta-analysis has shown that narrative report quality is universally poor.1 This is unacceptable, as operative reports contain critical patient care information. An established method of improving documentation quality is through synoptic reporting. Synoptic reports produce more comprehensive, accurate and reliable information than their narrative counterparts.1 Additionally, synoptic reports collect important quality indicators (QIs), facilitating timely research and policy change that may lead to care improvements.1 The American College of Surgeons’ National Accreditation Program for Rectal Cancer requires institutions to use synoptic pathology and radiology reports.2 Synoptic reports are also used for total mesorectal excision (TME).2^,3 Transanal endoscopic surgery (TES) is a novel surgical technique developed to improve local excision of rectal neoplasms. The technique is widely accepted for removal of neoplastic polyps and early-stage cancers. Additionally, it is increasingly being used for more advanced malignant lesions in conjunction with adjuvant therapies. While synoptic reports based on QIs have been developed for other rectal cancer procedures,2^,3 none exist for TES. Therefore, we devised an online Delphi process including physician stakeholders from across Canada to develop consensus-derived QIs for TES procedures, to ultimately develop a TES synoptic reporting template.

The Delphi process is shown in Figure 1; 67 items reached final inclusion (Table 1), and 12 were excluded (Table 2). Participants were 9 colorectal surgeons who regularly perform TES, a surgical oncologist, a general surgeon with expertise in synoptic operative reporting, 2 gastrointestinal (GI) pathologists, an abdominal radiologist and a radiation oncologist.

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Fig. 1

Flow diagram of the Delphi process to establish consensus-derived quality indicators for a transanal endoscopic surgery (TES) operative report. Participants submitted potential items, then rated them on a 9-point Likert scale. Items scoring 70% or higher were included, whereas scores of 30% or lower were excluded. Items scoring between 30% and 70% were recirculated.

Stakeholders from a variety of fields were included to ensure all relevant disciplines for rectal cancer care had input into this report as a communication tool. Rectal cancer care frequently involves a multidisciplinary team that must communicate effectively to make complex medical decisions. Many team members are not present during the surgical procedure, thus there is a particular need for excellent communication. Documentation of relevant findings is essential to make appropriate treatment decisions, such as the decision whether to provide adjuvant therapies or consider further resection.3 As familiarity with TES increases and the purported indications continue to expand, the intricacies of treatment decisions will increase, as will the importance of adequate documentation.

Synoptic reporting has been well-established in oncology, with pathologists being among the first in medicine to adopt and regulate standardized reporting more than 20 years ago. Standardized synoptic reports have been shown to improve communication and increase report quality.1 More recently, operative reports for rectal cancer TME have transitioned to a synoptic template, with excellent results.2^,3 Until now, TES has eluded requirements for standardized reporting, which leaves a growing segment of cancers and precancerous lesions treated via this technique without standardized documentation. The accuracy of TES reports are currently unclear, as there are no pre-existing reporting QIs with which to assess this procedure. However, it is widely described that traditional narrative reports have been inadequate for nearly all surgical procedures.1 To bring TES in line with other oncologic operations, development of standardized reports is the next logical step to assess and improve communication for this procedure.

Our survey identified 67 QIs upon which to establish a standard report, and can be used to evaluate existing TES documentation. The number of QIs proposed is similar to previous research on operative reporting,1^,3^,4 and is necessarily large. The operative report is an opportunity for a single document to contain much valuable information related to the patient’s surgical care. However, the need for creating such reports should be balanced with time constraints and workload for the reporting surgeon. A sample synoptic report for TES based on consensus-derived QIs is shown in Figure 2.

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Fig. 2

A sample synoptic report for transanal endoscopic surgery (TES) based on the consensus-derived quality indicators (QIs). BMI = body mass index; CEA = carcinoembryonic antigen; CT = computed tomography; DVT = deep vein thrombosis; MRI = magnetic resonance imaging; N/A = not applicable; PGY = postgraduate year; TAMIS = transanal minimally invasive surgery.

Many of the proposed QIs, particularly in the realms of patient demographics and preoperative work-up, could already be documented in the patient’s chart from preoperative, anesthesiology and/or nursing records. For the surgeon to manually input 67 items for every procedure would be arduous, although it is done regularly for other procedures.3^,5 For example, synoptic reports containing 75 items (all manually inputted) for Roux-en-Y gastric bypass at our own institution took on average 3 minutes, 55 seconds to complete, and were nearly 1 minute faster to complete than unstructured, dictated narrative reports.5 We anticipate that a synoptic report using our suggested TES QIs would have a similar duration. For these synoptic reports to be further optimized, effective integration into existing electronic medical records is key. In our own institution, Web Surgical Medical Record (WebSMR) is used to generate synoptic reports for other colorectal procedures. Using this system, 41 of the current TES QIs could be prepopulated from the chart. This would leave only 26 items (those indicated in bold in Table 1) for the surgeon to input, thus permitting more time to document information such as operative procedure details, of which only they have a full understanding. This reduced number is comparable to the 20 items in the American Society of Colon and Rectal Surgeons (ASCRS) synoptic report for TME.2 Previous research highlights the importance of also allowing free-text sections in synoptic reports, particularly during early implementation phases, to ensure inclusion of unexpectedly important details that may otherwise be missed.2

Another consideration is how TES, a seemingly less complex procedure than TME, could require more documentation items in the operative report. The most recent 20-item ASCRS report for TME has been piloted in multiple institutions and was abbreviated for feasibility.2 It is possible that, after prospective field testing of the current TES QIs described herein, the synoptic template could be shortened to a similar length as the ASCRS TME report (e.g., by removing some of the elements already documented elsewhere in the chart) if required.

• Accepted November 17, 2021.