Vattikonda, Asrita

Introduction: Advance care planning (ACP) supports goal-concordant care but remains underused nationally. In resident clinics, limited continuity, short visits, and lack of standardized workflows create barriers to ACP integration. In our Community Internal Medicine resident clinic, ACP discussion was documented in 2.5% of annual physicals, and 19.6% of paneled patients had an advance directive (AD) on file. We aimed to increase ACP documentation from 2.5% to 12.5% within 1 year without increasing perceived resident workflow burden. Methods: We conducted a resident-led quality improvement project using Lean Six Sigma methodology. Three interventions were implemented sequentially: nursing distribution of ACP brochures, an electronic medical record DotPhrase to prompt and document ACP discussions, and targeted patient portal outreach to patients without an AD before annual visits. The primary outcome was documented ACP discussion during annual physicals. Secondary outcomes included AD uploads and ACP consult referrals. The balancing measure was resident-perceived workflow burden. Charts were reviewed over 5-week periods at baseline (n = 118) and after each implementation phase (n = 132, 158, 129). Results: ACP documentation increased from 2.5% at baseline to 12.2%, 17.1%, and 24.0% across sequential phases (χ 2 (3) = 24.74, P < 0.0001). Pairwise comparisons versus baseline were significant (all P ≤ 0.005). AD upload rate increased from 1.7 to 6.0 per month, and ACP consult referrals increased from 0.0% to 10.9%. Mean perceived workflow burden decreased from 4.9 to 3.0. Conclusion: Workflow-embedded interventions improved ACP documentation, AD uploads, and ACP referrals without increasing perceived resident burden.

ABSTRACT Following a routine screening colonoscopy, a 54-year-old man underwent colon resection for adenocarcinoma, which revealed neoplastic B-cells in the lymph nodes surrounding the colon suggestive of chronic lymphocytic leukemia (CLL). Further evaluation identified a monoclonal B-cell population, and he was diagnosed with monoclonal B-cell lymphocytosis without meeting CLL diagnostic criteria. The patient had no clinical signs of leukemia and did not need acute treatment but was placed under annual surveillance. This case highlights the incidental discovery of neoplastic B-cells, emphasizing the importance of comprehensive histopathological evaluation and clinical correlation to guide management and monitoring for potential progression to CLL.

Abstract Background Colorectal surgery in patients with inflammatory bowel disease (IBD) and cirrhosis has increased morbidity, which may preclude surgery. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is postulated to reduce surgical risk. In this retrospective single-center study, we characterized perioperative outcomes in patients with IBD and cirrhosis who underwent preoperative TIPS. Methods We identified patients with IBD and cirrhosis who had undergone preoperative TIPS for portal decompression between 2010 and 2023. All other indications for TIPS led to patient exclusion. Demographic and medical data were collected, including portal pressure measurements. Primary outcome of interest was perioperative outcomes. Results Ten patients met the inclusion criteria. The most common surgical indications were dysplasia (50%) and refractory IBD (50%). TIPS was performed at a median of 47 days (IQR 34–80) before surgery, with reduction in portal pressures (22.5 vs. 18.5 mmHg, P &lt; .01) and portosystemic gradient (12.5 vs. 5.5 mmHg, P &lt; .01). Perioperative complications occurred in 80% of patients, including surgical site bleeding (30%), wound dehiscence (10%), systemic infection (30%), liver function elevation (50%), and coagulopathy (50%). No patients required re-operation, with median length of stay being 7 days (IQR 5.5–9.3). The 30-day readmission rate was 40%, most commonly for infection (75%), with 2 patients having intra-abdominal abscesses and 1 patient with concern for bowel ischemia. Ninety-day and one-year survival was 100% and 90%, respectively. Patients with primary sclerosing cholangitis (PSC)-cirrhosis were noted to have higher perioperative morbidity and a 30-day readmission rate. Conclusions In patients with IBD and cirrhosis, preoperative TIPS facilitated successful surgical intervention despite heightened risk. Nevertheless, significant complications were noted, in particular for patients with PSC-cirrhosis.

Abstract Background Colorectal surgery in patients with inflammatory bowel disease (IBD) and cirrhosis is associated with high morbidity related to portal hypertension. Thought to reduce surgical risk, transjugular intrahepatic portosystemic shunt (TIPS) may be used to decrease portal pressures. In this study, we aimed to characterize surgical outcomes of patients with IBD and cirrhosis who underwent preoperative TIPS at a large tertiary care center. Methods We retrospectively identified patients with IBD and cirrhosis who had undergone TIPS between 2010-2023 for portal decompression prior to colorectal surgery. All other indications for TIPS led to patient exclusion. Demographic and medical data was collected, including surgical indication and portal pressure measurement. Data on surgical outcomes were compiled through chart review. Results We identified 10 patients (60% male) with IBD and history of decompensated cirrhosis who underwent preoperative TIPS for portal decompression (Table 1). Surgical indications were colonic dysplasia (50%), refractory IBD (50%), and stenosis or stricture (30%). All patients were deemed nonsurgical candidates due to significant surgical risk from portal hypertension. Following multidisciplinary coordination, patients underwent TIPS for portal decompression at a median of 47 days (IQR 34-80) prior to colorectal surgery. TIPS was associated with significant reduction in portal pressure (22.5 vs 18.5mmHg, p&lt;0.01) and portosystemic gradient (12.5 vs 5.5mmHg, p&lt;0.01) in all patients. Of 10 patients, 30% had TIPS-related complications (transient fluid overload and encephalopathy). In terms of surgical complications, 40% of patients required intraoperative blood transfusion (range: 1-4 units). Postoperatively, 30% of patients had surgical site bleeding and 10% had wound dehiscence, although none required reoperation. Systemic complications occurred in 30% of patients, with systemic signs of infection being the most common. Transaminitis (50%) and coagulopathy (40%) were also common. Median hospital stay was 7 days (IQR 5.5-9.3), with 40% of patients being readmitted within 30 days. Most common cause of readmission was systemic infection (75%), abdominal abscess (50%), or electrolyte abnormality (50%), with one patient requiring reoperation for wound dehiscence. Ninety-day and 1-year survival was 100% and 90% respectively. Conclusion In our series of patients with IBD and cirrhosis requiring surgery but deemed nonsurgical candidates, preoperative TIPS lead to portal decompression and facilitated successful surgical intervention despite heightened risk. Nevertheless, significant operative and postoperative complications were noted. Future studies are needed to determine optimal surgical timing following TIPS placement.