Oesoph DB audit Form

Informations

• Publié par: Oslu
• Nombre de lectures: 19
• Langue: English

Extrait

Oesophagectomy Audit collection form DEMOGRAPHICS Surgerybooked for: Patient NamePartner / Spouse Name: Address Contactdetails of close family member or friend other  thanspouse ( not living in the same house) Contact Name:  Relationshipto pt. D.O.B. Address: Sex: UR No. Telephone Telephone: General Practitioner:………………………………… …………………………….GP telephone GP Address:……...……………………………... …………………………….  …………………………….……….  ……………………………………. Consultant: …………………………………………. Public / Private Hospital: ………………………………………….

Comorbities Details Heart diseaseY / N Respiratory diseaseY / N Diabetes Y/ N Renal Y/ N Obesity Y/ N Reflux diseaseY / NDuration: lessthan one year / 1 – 5 years / greater than 5 years Heartburn: never/ once a month / few times a week / daily / Previous heartburn  followedby recent disappearance of heartburn Regurgitation: never / once a month / few times a week / daily Other Y/ N Smoker:Smoker / Ex smoker / Never SmokedMedications :  Packyears _______ Alcohol: 0/ 1-2 / 3-5 / 6-9 / 10-15 / >15 standard drinks per week 1 standard drink= 1glass of beer  1glass wine Regular NSAID or Aspirin useY / N  1single spirit Please return completed form to Clinical Trials Assistant, University Department of Surgery, Level 5, EHB, Royal Adelaide Hospital

PRESENTATION Symptoms: Duration:  Dysphagia(Solids / liquids & solids)Y / N ………. Vomiting Y/ N ……….  WeightLoss Y/ N…………kg over ………. Months  RefluxY / N ……….  Pain(specify) Y/ N ……….  Other(specify) Y/ N ………. Initial Investigation leading to diagnosis:Endoscopy / Bariummeal / Other(please state) Date diagnosed: Results of Investigations Pre-Treatment Endoscopy :  Y / N Barium meal: Y / NEndoscopic US: Y / N Date: …………………… Date: …………Date: ……………….. Site of tumour: Site of tumour:Staging:  Proximalthird  Proximalthird T0  Middlethird  Middlethird Tis  Distalthird  Distalthird T1  GastroesophagealJunction  GastroesophagealJunction T2  T3 Length: Length:  T4 Dilated: Y/ N Nodal Involvement: NX – Regional lymph nodes Barretts: Y/ N  cannotbe assessed hiatus hernia:Y / N  N0– No regional lymph node  metastases Histology:  N1– Regional lymph node  Squamouscell carcinoma  metastases  Adenocarcinoma  Mixed CT Chest/Abdomen: Y/NPET ScanningY / NPreop Bloods Date: …………………………… Date:………………….. Date: …………………. site of tumour:Metastases: Y/ NSpecify level if abnormal  Proximalthird Location of Metastases:  Middlethird Hb: Normal/ abnormal  Distalthird  CardiaCreatinine: Normal/ abnormal Comments:  GastroesophagealJunction Albumin: Normal/ abnormal Wall thickeningY/N LFTs Normal/ abnormal Nodes Y/N Urea Normal/ abnormal  IfY where: C Reactive Protein Normal / abnormal Lung MetsY/N Liver MetsY/N Other findings:

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Results of Investigations Pre-Treatment (continued) Staging Laparoscopy :  Y / N MRI: Y / N Date: …………………… Date: ………… Site of tumour: Metastasis: Y/ N  Proximalthird  Middlethird  Peritonealmetastasis  Distalthird  Livermetastasis  GastroesophagealJunction  UnresectableLocal Disease Length: Details: Metastasis: Y/ N  Details:

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ANAESTHETIC WORK UP Pulmonary Function Tests:Obstructive / restrictive/ abnormal(Specify abnormalities) normal  Mild/ Moderate / Severe Echocardiogram:(Specify abnormalities)  Ventricularfunction: normal/ abnormal  ValvularDisease: yes/ no ECG: (Specifyabnormalities)  Normal/ abnormal PREOPERATIVE CHEMORADIOTHERAPY Radiotherapy:Y / N Chemotherapy:Y / N Type: Type:  Duration:…… weeksDate completed:… … … … … … …completed: …weeks DateDuration: ……  Dose:  Dose:  Lowdose / Full Dose  Lowdose / Full Dose Results of Investigations Post-Treatment Endoscopy :  Y / N Barium meal:  Y / N Endoscopic US:  Y / N Date: …………………… Date: …………Date: ……………….. Site of tumour:Proximal third Site of tumour:Proximal thirdStaging: T0  Middlethird  Middlethird Tis  Distalthird  Distalthird T1  Gastroesophageal  GastroesophagealT2  Junction  JunctionT3 Length: T4 Length: Nodal Involvement: Barrett’s: Y/ N  NX– Regional lymph nodes Dilated:Y / N  cannotbe assessed  N0– No regional lymph node hiatus hernia:Y / N  metastases  N1– Regional lymph node  metastases CT Chest/Abdomen :  Y/ N PET Scanning Y / N Preop Bloods Date: …………………………… Date: ………………….. Date : ………………… Site of tumour:Proximal third Metastases: Y/ NSpecify level if abnormal  Middlethird  Distalthird Location of Metastases:  Gastroesophageal / abnormalHb: Normal  Junction Creatinine: Normal/ abnormal Comments: Wall thickeningY/N Albumin: Normal/ abnormal Nodes Y/N LFT’s Normal/ abnormal  IfY where: Urea Normal/ abnormal Lung MetsY/N C Reactive Protein Normal / abnormal Liver MetsY/N Other findings:

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ANAESTHETIC ASA Status:1 / 2 / 3 / 4 / 5Preop Weight:…………..kgs Height: …………cm Anaesthetist: AnaestheticEvents: (OLA= one lung anaesthesia) Double Lumen TubeY / N Pre OLA- hypoxia Thoracic epiduralY / N- hypotension - arrhythmia Analgesia:  PCA On OLA- hypoxia  Epiduralperiop / postop / both- hypotension  -arrhythmia Extubated / Intubated at end of case OLA possibleY / N Any problems:If no why: SURGERY Type of Procedure: Date of Surgery:- Thoraco-abdominal / cervico-abdominal / Duration of Surgery :………..minutes cervico-thoraco-abdominal Type of Anastomosis:Chest: open/ laparoscopic / converted  -Handsewn continuous Abdomen: open / laparoscopic / converted  -Handsewn interrupted  -Stapled Surgeon Assistant  staplersize ………… Neck Anit-Reflux procedure:  -None  - Partial Chest  -Total Abdomen Feeding jejunostomyY / N Drains: -chestY / N Blood loss  -abdomenY / N  -estimate …………mls Drainage procedure: none / Pyloroplasty / Pyloromyotomy Transfusion Y/ N  /Pyloromyomectomy  -In theatre Complications / Comments : - -Post-op - No. of units:………….

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POSTOPERATIVE DETAILSPatient Name:DOB:  UR:Surgery Date:DB Ref: ICU stay… ……….day(s) ReadmissionICU or HDUY/N HDU stay………….day(s)Reintubated Y/N Ventilated Y/ NICU/HDU Readmission details:  No.of days ventilated ………… Ionotropes Y/N Reoperation requiredY / N Reoperation details: Complications :( Clinically significant causing prolonged hospital stay & / or patient suffering) Y / NAnastomotic leak - clinicalY / NChest infection  Anastomoticleak -sub-clinicalY / NIleus Y/ N  Respiratoryfailure Y/ NCardiac eventY / N  Renalfailure Y/ NWound infectionY / N  Multiorgan failureY / NOther (specify)  Septicshock Y/ N Barium swallow Result  Y/ N Postop day ……………

Commenced oral fluids day ………….postop Discharged/Died :Date …… … … … Commenced oral solids day………… postop Died day ………….. post op Total Hospital Stay………… days HISTOLOGY Laboratory:Gribbles Clin IMVS& MowerPath King Tumour site:Depth of Invasion:  Proximalthird TO– no evidence of primary tumour  Middlethird TiS– High grade dysplasia  Distalthird T1– Tumour invades lamina propria,  Cardiamuscularis mucosa or submucosa  GastroesophagealJunction T2– Tumour invades muscularis propria  T3– Tumour invades paraoesophageal tissue Tumour Type:  T4– Tumour invades adjacent structures  Squamouscell carcinoma  Adenocarcinoma Tumour differentiation:  Mixed Well differentiated  Other  Moderatelydifferentiated Barretts: present Moderate – poorly differentiated / absent Poorly differentiated Nodal Involvement: COX Staining:Not done / present / absent  NX– Regional lymph nodes cannot be assessed  N0– No regional lymph node metastases Based on Histology and Surgical findings:  N1– Regional lymph node metastases - ProbableCurative Resection Proximal Margin: - PossibleCurative Resection  involved/ free of tumour -Palliative Resection Distal Margin :Involved / free of tumour To be returned to Clinical Trials Assistant, Department of Surgery, L5 EHB, RAH, on discharge of Patient from Hospital - 6 -