Outcomes. Digestive Disease Institute

Transcription

1 Outcomes 2008 Digestive Disease Institute

2 Institute Overview 2

3 Surgical Overview To promote quality improvement, Cleveland Clinic has created a series of Outcomes books similar to this one for many of its institutes. Designed for a physician audience, the Outcomes books contain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a review of new technologies and innovations. Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic omission of outcomes for a particular treatment does not mean we necessarily do not offer that treatment our goal is to increase unavailable, we often report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical techniques. In addition to our internal efforts to measure clinical quality, Cleveland Clinic supports transparent public reporting of healthcare quality data and participates in the following public reporting initiatives: ( ( Our commitment to providing accurate, timely information about patient care will also help patients and referring physicians make informed healthcare decisions. quality/outcomes. Digestive Disease Institute 1

4 Dear Colleague, On behalf of Cleveland Clinic, I am pleased to present our 2008 Outcomes books. The primary purpose of our annual Outcomes book initiative is to promote quality improvement at Cleveland Clinic, thereby optimizing the care we provide to our accountability, transparency and results. requiring hospitals to report more and more quality and patient safety data. We view our Outcomes books as voluntary supplements to the required public reporting and an opportunity to share selected innovations with colleagues across the country. Designed for the physician reader, each book in the annual series focuses on care provided by one of our patient-centered content informative. 2 Outcomes 2008

5 what s inside Institute Overview 05 Quality and Outcomes Measures Anorectal Disease 06 Esophageal Cancer 28 Nursing Quality 29 Contact Information 50 Cleveland Clinic Overview 52 Digestive Disease Institute 3

6 Chairman s Letter Thank you for your interest in the Cleveland Clinic Digestive Disease Institute (DDI) 2008 Outcomes. This is the seventh year that we have shared our clinical outcomes and advanced technology with referring physicians, alumni, potential patients and other individuals interested in digestive diseases around the country. includes the liver transplant team, nutrition therapy, nutrition support, intestinal rehabilitation and transplant nutrition, and upper gastrointestinal surgery along with the former Digestive Disease Center s departments of colorectal surgery and gastroenterology and hepatology. reorganization as this close-knit team of healthcare providers draws on each across the nation and from around the world. The institute is the largest national referral center for repairing failed pelvic pouches and houses and treatment of digestive diseases, which you can read about in the pages that follow. It was also the year that who I have mentored for many years here at Cleveland Clinic, will carry on the department s reputation of both quality and compassion. Digestive Disease Outcomes useful both as a reference as well as a testimony to our commitment to continuously raise the standards of our patient-centered care. Chairman, Digestive Disease Institute 4 Outcomes 2008

7 Institute Overview 2008 Statistics Admissions 5,398 Patient Days 39,033 Average Length of Stay 7.2 Total Visits 100,954 Surgical Cases 5,092 Endoscopic Cases 33,269 and hepatology, colorectal surgery, hepato-pancreato-biliary and transplant surgery, and nutrition within one unique, fully integrated model of care aimed at optimizing the treatments performed in the most effective and patient-friendly way, including shorter waits for appointments and more seamless interaction with all of our specialists. In addition, our institute model enhances opportunities for cutting-edge research and physician education. U.S.News & World Report s Digestive Disease Institute 5

8 Surgical Anorectal Overview Disease Diseases We Treat Anal Cancer Polyps Abscess Fistula Fissure Hemorrhoids Pruritis Ani Bowen s Disease Paget s Disease Anal Intraepithelial Neoplasia Techniques We Use Combined Modality Therapy for Anal Cancer Transanal Excision and TEM Fistula Plug Advancement Flaps Seton Insertion Episioproctomy Sphincterotomy Botox Injection Stapled, Doppler-Guided, and Conventional Hemorrhoidectomy High-Resolution Anoscopy Hemorrhoids Cleveland Clinic s Digestive Disease Institute offers patients all available techniques to treat hemorrhoids from banding to hemorrhoidal arterial ligation to staple and conventional surgical techniques proven to provide good outcomes. Procedure Volumes and Percent Recurrence (1 year) for Treatment of Hemorrhoids Volume Recurrence (%) Hemorrhoidal Banding Hemorrhoidal arterial ligation Stapled hemorrhoidectomy Excisional hemorrhoidectomy 0 Treatment 6 Outcomes 2008

9 Anal Fistula and Rectovaginal Fistula operative techniques that are determined by the etiology and precise anatomy of plug and other cutting edge treatments in the result of failed prior attempts at cures, In many cases, despite the challenges of Procedure Volumes and Percent Recurrence (1 year) for Treatment of Anal and Rectovaginal Fistula Volume Recurrence (%) Fistulotomy Fistulectomy Complex Treatment Anal and Rectovaginal Rectovaginal Fistula Complex Anal Fissures 60 percent when treated conservatively. Cleveland Clinic s Digestive Disease Institute offers minimally invasive and traditional surgical options to increase healing rates in patients whose treatment or have failed therapy at other institutions. Careful patient selection and a focus on changing bowel habits can decrease the chances of recurrence. Procedure Volumes and Percent Recurrence (1 year) for Treatment of Anal Fissures Volume Recurrence (%) Fissurectomy Botox injection Lateral internal sphincterotomy 0 Treatment Digestive Disease Institute 7

10 Constipation, Rectal Prolapse, Fecal Incontinence Constipation patients and their physicians. In 2008, we performed nearly 60 surgical procedures to treat the different causes of severe constipation. The two most commonly performed procedures, Constipation Patients with Symptom Improvements as a Result of Surgery (N = 60) 2008 Percent Improvement Abdominal Colectomy IRA Surgical Procedure Stoma specialized surgical procedure that preserves the colon and is used in select cases of severe constipation. Constipation - Comparison of Pre- and Post Op Patients following ACE Procedure (N = 9) 2008 Occurrences per Week 8 6 Pre-Op Post-Op Bowel Movements Laxatives Retrograde Enemas Fecal Incontinence (Episodes) Abdominal Pain (Episodes) 8 Outcomes 2008

11 Rectal Prolapse In 2007 through 2008, we performed 31 surgical procedures for rectal prolapse including 14 perineal procedures and 17 abdominal procedures. A laparoscopic approach was used for the majority of the abdominal procedures. More than 80 percent of patients experienced symptomatic improvement. At one year follow-up, 100 percent and 86 percent of patients who underwent abdominal and perineal procedures respectively were free of recurrent prolapse. Fecal Incontinence Overlapping sphincteroplasty was used to treat fecal incontinence in 61 patients in 2007 and More than 80 percent of patients improved control following sphincteroplasty. Quality of life related to control of bowel movements also was markedly improved after sphincteroplasty. (Charts below) FIQL: Comparison Between Pre- and Post-Sphincteroplasty (N = 61) Percent Improved Worse Same 20 0 Lifestyle Score Coping/Behavior Depression Embarrassment FIQL scales FIQL: Fecal Incontinence Quality of Life - Improvement noted in all domains SF-12: Comparison Between Pre- and Post-Sphincteroplasty (N = 61) Percent Improved Worse Same 0 SF-12 scores Digestive Disease Institute 9

12 Colon and Rectal Cancer Cleveland Clinic s Digestive Disease Institute is a leader in both prevention and treatment of colon and rectal polyps and cancer. Using a multidisciplinary approach Digestive Disease Institute provides world-class care through patient screening, education, detection, and treatment. Effect of Time of Colonoscopy on Adenoma Detection Rate (N = 3,619) Percent Rate Morning Afternoon Adenoma Detection A recent study from the Institute provided information that could lead to an in 2006 at Cleveland Clinic. Detecting at least one adenoma was considered a positive colonoscopy. Colonoscopies performed in the morning had a higher rate of adenoma detection than those performed in the afternoon. The adenoma detection group (p = 0.008). This study accounted for variability in bowel preparation and p = 0.006]. This information has led to further studies as to why this phenomenon was observed and how the detection rate may be improved. 10 Outcomes 2008

13 5-Year Survival Curves (Kaplan-Meier) for Colon Cancer by Stage Proportion DFS Survival %, Stage 1, N = %, Stage 2, N = %, Stage 3, N = %, Stage 4, N = Months from Surgery Treating colon and rectal cancer is often a multimodal approach with surgery as the cornerstone of care. The Cleveland Clinic s Digestive Disease Institute treats one of the highest volumes of colorectal cancer patients in the country. Institute surgeons Digestive Disease Institute 11

14 Colon and Rectal Cancer Rectal Cancer Colostomy avoidance is one goal of rectal cancer surgery. Digestive Disease Institute colorectal surgeons were able to avoid a permanent colostomy in 67 percent, despite the complex presentation of many of our rectal cancer patients. Types of Surgery Performed for Rectal Cancer: Procedures (%) Sphincter saving procedure Resection and Colostomy Local excision/treatment Other Treatments Year Survival Curves (Kaplan-Meier) for Rectal Cancer by Stage Proportion DFS Survival %, Stage 1, N = 1, %, Stage 2, N = %, Stage 3, N = %, Stage 4, N = Months from Surgery 12 Outcomes 2008

15 Rectal Cancer Recurrence Rates Optimal surgery combined with proper use of chemotherapy and radiation resulted in low rates of local recurrence for rectal cancer patients. In 2008, the local recurrence rate for rectal cancer was less than 1 percent, 3 percent and 4 percent for upper, middle, and low rectal cancers respectively. Recal Cancer Recurrence Rate 2008 Percent Upper Third Middle Third Lower Third Rectal Cancer Laparoscopic Surgery in the Treatment of Colorectal Cancer Laparoscopic surgery for colorectal cancer was shown to result in cancer-related outcomes similar to those of traditional open surgery. Advantages of the laparoscopic approach include decreased hospital stay, decreased pain and more rapid recovery. In 2008, approximately 50 percent of colorectal cancer operations were performed by laparoscopic approach. Comparison on Median Length of Stay for Colorectal Cancer Laparoscopic vs. Open Open Surgery N Median LOS Partial Colectomy 89 6 Anterior Resection 83 7 Total Laparoscopic Surgery Partial Colectomy Anterior Resection 15 5 Total LOS: Length of stay after surgery Digestive Disease Institute 13

16 Colon and Rectal Cancer Colorectal Cancer in the Elderly often have associated medical comorbidities that affect their ability to tolerate surgery rectal cancer, stage-for-stage. 5-Year Disease-Free Survival for Stage I-III Colon Cancer by Age Proportion DFS Survival >75, N = Months from Surgery 14 Outcomes 2008

17 Jagelman Registries Center is composed of physicians, researchers and nurses from several institutes including the to provide outstanding clinical care, education to caregivers, patients and families, and to research hereditary colorectal cancer. Jagelman Registry Numbers 2% Hyperplastic Polyposis (17) 3% Peutz-Jehgers (27) 4% Juvenile Polyposis (34) 2% MYH-associated Polyposis (13) 89% Familial Adenoma Polyposis (754) Digestive Disease Institute 15

18 Colon and Rectal Cancer Effect of Chemoprevention on Familial Adenoma Polyposis A 2008 Digestive Disease Institute study evaluated the effect of chemoprevention on the rate of rectal cancer and proctectomy in 290 patients with familial adenomatous receiving chemoprevention were less likely to undergo proctectomy, develop rectal cancer, or die from their disease. No Chemoprevention (CP) Chemoprevention (CP) Proportion Without Cancer or Proctectomy No CP CP p < Years since IRA 16 Outcomes 2008

19 Diverticular Disease surgery. A further cohort is referred for reconstructive surgery, having had an emergency procedure performed elsewhere. Diverticular Operations - Volumes and Length of Stay 2008 N Median Length of Stay Complications of Primary Resection and Anastomosis vs. Hartmann Reversal Procedure Primary Resection / Anastomosis n (%) Hartmann Reveral n (%) P-value associated with a higher prevalence of surgical or medical complications compared with primary resection and anastomosis. postoperative period. Our results add emphasis to importance of timely and appropriate surgery for sigmoid diverticulitis so a Digestive Disease Institute 17

20 Patients Who Underwent Repeat Pouch Surgery to Salvage a Failed Pouch and Avoid Permanent Ileostomy. Variable Abdominal Repeat Pouch Primary IPAA Group P-value Surgery Group IPAA: ileal pouch-anal anastomosis CGQL: In 2008, we continued our tradition of providing the highest level of care to patients with Crohn s disease, ulcerative colitis 18 Outcomes 2008

21 Ileoanal Pouch for Crohn s Disease Patients Diagnosis of Crohn s Disease (CD) in Patients with Restorative Proctocolectomy and Ileal Pouch-Anal Anastomosis. (N = 204) Intentional Incidental Delayed Post-Operative Outcomes in Patients with Intentional or Incidental Pouch with Crohn s Disease Versus Delayed Diagnosis of Crohn s Disease. Outcome Overall Intentional or Delayed CD P-value Incidental diagnosis CD Pouch Digestive Disease Institute 19

22 Inflammatory Bowel Disease Infliximab (Remicade) Use Increased Frequency of Complications in Patients with Both Crohn s Disease and Ulcerative Colitis A recent study performed by Digestive Disease Institute colorectal surgeons suggests that the surgical approach to ulcerative colitis may require modifications in ulcerative colitis patients treated with infliximab. Infliximab Non-Infliximab P-value Sepsis 10 (22%) 1 (2%) Leak 8 (17%) 1 (2%) Overall early postoperative complication 16 (35%) 7 (15%) Pouchitis 18 (39%) 7 (15%) Stricture 5 (11%) 9 (20%) 0.39 SBO 3 (6.5%) 6 (13.0%) 0.45 Overall late postoperative complication 24 (52%) 17 (37%) 0.23 The increased incidence of septic complications in ulcerative colitis patients treated with infliximab has resulted in increased use of three stage pouch procedures in this patient population with the aim of decreased post-operative complications. Inflammatory Bowel Disease Complications and Functional Results After Ileoanal Pouch Formation in Obese Patients Ileoanal pouch formation (IPAA) can be technically challenging in obese patients, and there is little data evaluating results after the procedure in these patients. We compared outcomes for patients with a body mass index (BMI) 30 or more undergoing IPAA when compared with those for patients with BMI less than 30. RESULTS: Obese Not obese P-value N Pelvic Sepsis 6.7% 5.3% NS Pouch Failure 6% 4.5% NS Wound Infection 19% 8.1% P<.05 Anastomotic Leak 10% 5% p<.05 Long-term outcome including QOL and function after 15 years was comparable between groups. CONCLUSIONS: Although technically demanding, IPAA can be undertaken in obese patients with acceptable morbidity. Good long-term functional results and QOL that is comparable to nonobese patients may be anticipated. 20 Outcomes 2008

23 Short and Long-Term Morbidity of Ileal Pouch Anal Anastomosis (IPAA) Surgery We recently reported outcomes for all patients who underwent primary patients who underwent the procedure at a different center before being Surgical Technique for IPAA (N = 3,080) Early (30-day) Post-Operative Complications of IPAA (N = 3,080) Digestive Disease Institute 21

24 Ileal Pouch Failure Model Pr (pouch failure) years 10-years 5-years 3-years 1-year CCF-IPF score score as calculated by the Weibull survival probabilities are shown (orange circles). Total Morbidity for Crohn s Disease (N = 2,212) Year Volume 30 Day 30 Day Abdominal Obstruction Anast. Mortality (%) Readmission (%) Abscess (%) or Ileus (%) Leak (%) 22 Outcomes 2008

25 Incontinence Rare or No Incontinence Percentage BL 1 yr 5 yrs 15 yrs Time Post Surgery Bowel Movements: Frequency and about one to two times at night. These results were much better than prior to surgery. Digestive Disease Institute 23

26 Cleveland Clinic Quality of Life Score Mean QOL Score BL 1 yr 5 yrs 15 yrs Time Post Surgery Continent Ileostomy Continent ileostomy is an option in patients in whom an ileal pouch surgery is not possible or in whom the initial and subsequent repeat ileoanal pouch surgery failed and the patient is reluctant to accept a permanent ileostomy. Continent ileostomy, or Kock pouch, is constructed by three loops of small bowel and a one-way valve, which allows patients to avoid wearing an outer appliance. One has to cannulate the Kock pouch three or four times a day to empty itself. Cleveland Clinic Complications # of Patients % Koch Pouch Status # of Patients % 24 Outcomes 2008

27 Liver Disease Liver Transplantation the liver transplant program we have maintained graft and patient survival above the national average. Liver Transplant Volume Patients Year Digestive Disease Institute 25

28 Liver Disease Liver Transplant Patient Survival (Includes Liver/Heart, Liver/Kidney Liver/Lung and Liver/Pancreas) Percent Survival All Patients Months Survival Analysis: Patient survival for 587 primary liver, liver/heart, liver/kidney, liver/lung and liver/pancreas transplants Liver Transplant Graft Survival (Includes Liver/Heart, Liver/Kidney Liver/Lung and Liver/Pancreas) Percent Survival All Patients Months Survival Analysis: Liver graft survival for 587 primary liver, liver/heart, liver/kidney, liver/lung and liver/pancreas transplants Outcomes 2008

29 Intestinal Rehabilitation and Transplant Program the Country was a very productive year for the Intestinal Intestinal Transplant in Ohio. reconstructive surgery or transplantation. A lesser percentage of referred patients were readmitted with lesser percentage of referred patients were discharged from the Digestive Disease Institute 27

30 Esophageal Cancer Early Esophageal Cancer in High-Risk Patients measured by histologic response rate and cancer-free survival at Cleveland Clinic s Digestive Disease Institute between patients with complete response had recurrence of dysplasia or cancer in the gastric cardia. year follow-up. Probability of Cancer Free Survival Proportion Cancer Free Upper and Lower Confidence Intervals Cancer-free Survival 0 Months Post-CSA N at Risk September 2005 September Outcomes 2008

31 Nursing Quality Inpatient Nursing Risk Assessment Improvement Percent Assess Skin on Admit Braden on Admit Daily Braden Done WOSCN position Results of 2008 WOSCN Survey: All Peers Peer Evaluation Averages Support of Bedside Nurse Overall Quality of Skin Care Nurse: MD Collaboration Overall Quality of Patient Care Digestive Disease Institute 29

32 Surgical Quality Improvement Hospital Compare: Surgical Care Improvement Project (SCIP) data showing how consistently they provide recommended care to adult patients, irrespective of payer. (These results also SCIP - Prophylactic Antibiotic Received within 1 Hour Prior to Surgical Incision (N = 902) National Average* 86 Cleveland Clinic Percent of Patients * Source: discharges July June Outcomes 2008

33 SCIP - Prophylactic Antibiotic Discontinued within 24 Hours After Surgery End Time (N = 813) National Average* 84 Cleveland Clinic Percent of Patients * Source: discharges July June 2008 SCIP - Prophylactic Antibiotic Selection for Surgical Patients (N = 937) National Average* 92 Cleveland Clinic Percent of Patients * Source: discharges July June 2008 Digestive Disease Institute 31

34 Surgical Quality Improvement SCIP - Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered (N = 677) National Average* 84 Cleveland Clinic Percent of Patients * Source: discharges July June 2008 SCIP - Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis within 24 Hours Prior to Surgery to 24 Hours After Surgery (N = 677) National Average* 81 Cleveland Clinic Percent of Patients * Source: discharges July June Outcomes 2008

35 SCIP - Surgery Patients with Appropriate Hair Removal (N = 1,386) National Average* 95 Cleveland Clinic Percent of Patients * Source: discharges January - June 2008 Digestive Disease Institute 33

36 Surgical Quality Improvement National Surgical Quality Improvement Project - Colorectal Surgery (N = 261) Percent Expected Observed Day Mortality 30-Day Morbidity Length of Stay* (N = 186) Surgical Site Infection *Length of stay for patients without complications morbidity outcomes and length-of-stay data are reported. Cleveland Clinic s most 34 Outcomes 2008

37 Leapfrog Survey - Pancreatic Resection One bar = willing to report data Two bars = some progress Three bars = substantial progress mistakes and improve the quality and affordability of pancreatic resection rating appears above. Digestive Disease Institute 35

38 Patient Experience Cleveland Clinic has placed a renewed emphasis on improving the patient that patients seek more than solely a successful clinical outcome, the mission the well-being of our patients, families and employees in a way that elevates Cleveland Clinic s reputation as one of the world s best hospitals. institutes to research and implement innovative patient- and family-based programs that support this mission. Outpatient Digestive Diseases Institute Overall Rating of Outpatient Care and Services Percent (N = 2,403) 2008 (N = 2,591) Excellent Very Good Good Fair Poor Source: Quality Data Management, a national hospital survey vendor 36 Outcomes 2008

39 Rating of Outpatient Provider Percent (N = 2,403) 2008 (N = 2,591) Excellent Very Good Good Fair Poor Source: Quality Data Management, a national hospital survey vendor Recommend Outpatient Provider Percent (N = 2,403) 2008 (N = 2,591) Extremely Likely Very Likely Somewhat Likely Source: Quality Data Management, a national hospital survey vendor Somewhat Unlikely Very Unlikely Digestive Disease Institute 37

40 Patient Experience Inpatient Digestive Diseases Institute reporting are available at HCAHPS Overall Assessment Percent % 61% Rate Hospital % respondents choosing 9 or total survey respondents = total survey respondents = 1,081 73% 73% Would Recommend % respondents choosing 'definitely yes' Source: Quality Data Management and Press Ganey, national hospital survey vendors For comparison purposes, 2007 and Q HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS. 38 Outcomes 2008

41 HCAHPS Domains of Care Percent Respondents choosing 'always' or 'yes' 2007 total survey respondents = total survey respondents = 1, Discharge Information Doctor Communication Nurse Communication Pain Management Room Clean Communication New Medications Responsiveness to Needs Quiet at Night Source: Quality Data Management and Press Ganey, national hospital survey vendors For comparison purposes, 2007 and Q HCAHPS scores have been adjusted to account for a survey mode administration change as recommended by CMS. Digestive Disease Institute 39

42 Innovations Endoscopic Cryospray Ablation less than one minute thaw time between applications. same vicinity treated by endoscopic mucosectomy or argon plasma coagulation. crycopharyngeal location (one stricture requiring temporary naso-enteric tube feeding and dilations, one stricture treated palliation gastrostomy or pharyngolaryngectomy. Two patients averted radiation therapy. One patient died of metastatic disease after a clinical response of the esophageal lesion and improvement in dysphagia. One patient with a crycopharyngeal 40 Outcomes 2008

43 Example of patient with invasive squamous cell cancer at the cricopharyngeus facing laryngectomy as an alternative to cryotherapy. By treating this early cancer with cryotherapy, the patient maintains ability to speak and swallow. Pre-procedure During procedure Post-procedure Minimally Invasive/Robotic Liver and Pancreas Surgery Program Minimally invasive techniques have been proven to benefit patients by decreasing length of hospital stay and time required to return to full activities. The surgical robot has allowed surgeons at DDI to expand minimally invasive surgery to the areas of liver and pancreas. The surgical robot incorporates 3D visualization with articulating instrumentation to give surgeons the dexterity of conventional open surgery while maintaining the benefits of the minimally invasive approach. Digestive Disease Institute 41

44 Selected Publications 200 Publications Digestive Disease Institute staff authored more than bowel disease genetics. Curr Opin Gastroenterol associated with adverse postoperative outcomes in Crohn s patients. J Gastrointest Surg technology to promote gastrointestinal outcomes research: a case for electronic health records. Am J Gastroenterol report of a rare indication for liver transplantation. Liver Transpl measurements improve the management of portosystemic shunts during liver transplantation. Liver Transpl colitis are attenuated in the absence of signal transducer Am J Pathol Outcomes 2008

45 and morbidity in patients with chronic intestinal failure including those who are referred for small bowel transplantation. Transplantation polyposis. Clin Gastroenterol Hepatol and distal splenorenal shunt. J Hepatol J Endourol of fatty liver and disease progression to steatohepatitis: implications for treatment. Am J Gastroenterol ed. Current Surgical Therapy staging system separates patients with intra-abdominal, familial adenomatous polyposis-associated desmoid disease by behavior and prognosis. Dis Colon Rectum sword has two edges. Dis Colon Rectum Digestive Disease Institute 43

46 Selected Publications what have we learned? A collection of perspectives and panel discussion. Cleve Clin J Med between donor-recipient serum sodium differences and orthotopic liver transplant graft function. Liver Transpl cost. Dis Colon Rectum for screening and surveillance of esophageal varices in patients with portal hypertension. Hepatology colon and rectal surgery. Clin Colon Rectal Surg techniques. Endoscopy Endoscopy Impact of orthotopic liver transplant for primary sclerosing cholangitis on chronic antibiotic refractory pouchitis. Clin Gastroenterol Hepatol for serrated colorectal cancer, selectively represses betacatenin-dependent transcription. Oncogene Oct Colorectal Dis of metabolic syndrome in the setting of recurrent hepatitis C after liver transplantation. Liver Transpl On-treatment prediction of response to peginterferon/ ribavirin therapy. Liver Transpl of metabolic syndrome in the setting of recurrent hepatitis C after liver transplantation. Liver Transpl liver transplantation. J Hepatobiliary Pancreat Surg. Female Urology lymphoproliferative disorders after liver transplantation in relation to age and duration of follow-up. Liver Transpl Outcomes 2008

47 manner. Transplantation Colon Rectal Surg Kelley DE. Estimates of hepatic glyceroneogenesis in type 2 diabetes mellitus in humans. Metabolism Dis Colon Rectum results after ileoanal pouch formation in obese patients. J Gastrointest Surg case in an unusual location. Tech Coloproctol Nat Clin Pract Gastroenterol Hepatol ulcerative colitis: a randomized placebo-controlled trial. Gastroenterology Hepatology patterns of use and effects on liver function. Am J Gastroenterol Incidental reduction in the size of liver hemangioma following J Hepatol pathology. Dis Colon Rectum Med Clin North Am of clinical outcomes in primary biliary cirrhosis by Hepatology ileal pouch-anal anastomosis and Crohn s disease: pouch retention and implications of delayed diagnosis. Ann Surg. with living liver donation. Transplant Rev (Orlando). Digestive Disease Institute 45

48 Selected Publications Neurogastroenterol Motil with an increased risk of postoperative complications after restorative proctocolectomy. Dis Colon Rectum after ileal pouch surgery for ulcerative colitis. Endoscopy. the early postoperative period with noninvasive indocyanine green elimination following orthotopic liver transplantation. Liver Transpl methylationalterations in endoscopic retrograde cholangiopancreatography brush samples of patients with suspected pancreaticobiliary disease. Clin Gastroenterol Hepatol spontaneous bacterial peritonitis. Gastroenterology cholangiopancreatography and pancreatic function test in suspected chronic pancreatitis and negative crosssectional imaging. Clin Gastroenterol Hepatol Adv Exp Med Biol of meperidine and midazolam during endoscopy. Clin Gastroenterol Hepatol is portal hyperperfusion, not arterial siphon. Liver Transpl. Will it ever yield grafts for two adults? Liver Transpl laparoscopy in colorectal surgery. Colorectal Dis disease: progress in basic and clinical science. Curr Opin Gastroenterol all responsible. Dis Colon Rectum associated complications after restorative proctocolectomy. Clin Gastroenterol Hepatol 46 Outcomes 2008

49 pouch failure in patients with different phenotypes of Crohn s disease of the pouch pouches. J Clin Gastroenterol anastomosis. Clin Gastroenterol Hepatol laparoscopic versus open ileocolic resection for Crohn s disease: follow-up of a prospective randomized trial. Surgery transplantation as a rescue operation for recurrent hepatocellular carcinoma after partial hepatectomy. World J Gastroenterol and endoscopic retrograde pancreatography for the prediction Dig Dis Sci secretin-stimulated endoscopic and Dreiling tube pancreatic function testing in patients evaluated for chronic pancreatitis. Gastrointest Endosc of a steroid-free regimen with thymoglobulin induction in pancreas-kidney transplantation. Transplant Proc mucosa in cirrhosis and portal hypertension. World J Gastroenterol aspiration for suspected pancreatic cystic neoplasms. JOP. of suspected pancreatic cystic neoplasms based on cyst size. Surgery Best Pract Res Clin Gastroenterol Digestive Disease Institute 47

50 Staff Listing Institute Chairman Department of Colorectal Surgery Chairman Department of Gastroenterology and Hepatology Chairman Colon Cancer Endoscopy Section Section Head Section Head Swallowing Center Section Head Nutrition Outcomes Section Clinical Hepatology Section Section Head 48 Outcomes 2008

51 Gastroenterology Regional Practice Department of Hepato-pancreato-biliary and Transplant Surgery Chairman Program and Surgical Director, Liver Transplantation Surgical Director, Intestinal Transplantation Vice Chairman, Department of Hepato-pancreato-biliary and Transplant Surgery Digestive Disease Institute Anesthesiology Section Head General and Liver Transplantation Anesthesiology Section Section Head Allen Keebler, DO clevelandclinic.org/staff. Digestive Disease Institute 49

52 Contact Information General Patient Referral Colorectal Surgery Appointments/Referrals Gastroenterology & Hepatology Appointments/Referrals Additional Contact Information General Information Hospital Patient Information Patient Appointments Medical Concierge for Out-of-State Patients Complimentary assistance for out-of-state patients and families Global Patient Services / International Center Complimentary assistance for international patients and families clevelandclinic.org/gps Cleveland Clinic in Florida For address corrections or changes, please call 50 Outcomes 2008

53 Institute Locations Main Campus/A Euclid Ave. Solon Family Health Center Beachwood Family Health and Surgery Center Hillcrest Hospital Atrium Elyria Chestnut Commons Family Health Center Strongsville Family Health and Surgery Center Westlake Family Health Center Willoughby Hills Family Health Center Independence Family Health Center Crown Center II Digestive Disease Institute 51

54 Cleveland Clinic Overview bundling all clinical specialties into integrated practice units called institutes. An institute combines all the under a single roof. Each institute has a single leadership and focuses the energies of multiple professionals onto the point-of-care service, institutes will improve the patient outpatient clinic, specialty institutes and supporting labs Cleveland Clinic Abu Dhabi (United Arab Emirates), a multispecialty care hospital and clinic, is scheduled to offers all students full tuition scholarships. The program will Cleveland Clinic is consistently ranked among the top hospitals in America by U.S.News & World Report, and our clevelandclinic.org. associates and postdoctoral fellows are involved in laboratory-based, translational and clinical research. Total federal agencies, non-federal societies and associations, endowment funds and other sources. In an effort to bring research from bench to bedside, Cleveland Clinic at any given time. 52 Outcomes 2008

55 Resources for Physicians Cleveland Clinic Secure Online Services Cleveland Clinic uses state-of-the-art digital information systems to offer secure online services such as online medical second opinions, medical record access, patient treatment progress for referring physicians (see below), and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org. MyChart This secure online tool connects patients to their own health information from the privacy of their home any time, day or night. Some features include renewing prescriptions, reviewing test results and viewing medications, all online. For the convenience of physicians and patients across the country, MyChart now offers a secure connection to Google TM Health. Google Health users can securely share personal health information with Cleveland Clinic, and record and share the details of their Cleveland Clinic treatment with the physicians and healthcare providers of their choice. To establish a MyChart account, visit clevelandclinic.org/mychart. DrConnect Whether you are referring from near or far, DrConnect streamlines communication from Cleveland Clinic physicians to your office. This complimentary online tool offers secure access to your patient s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient s care using the secure DrConnect website. To establish a DrConnect account, visit clevelandclinic.org/ drconnect or drconnect@ccf.org. MyConsult Online Medical Second Opinion This secure online service provides specialist consultations from our Cleveland Clinic experts and remote medical second opinions for more than 1,000 life-threatening and lifealtering diagnoses. MyConsult is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit clevelandclinic.org/myconsult, eclevelandclinic@ccf.org or call , ext Critical Care Transport: Anywhere in the world Cleveland Clinic s critical care transport team serves critically ill and highly complex patients across the globe. The transport fleet comprises mobile ICU vehicles, helicopters and fixed-wing aircraft. The transport teams are staffed by physicians, critical care nurse practitioners, critical care nurses, paramedics and ancillary staff, and are customized to meet the needs of the patient. Critical care transport is available for children and adults. To arrange a transfer for STEMI (ST elevated myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage) or aortic syndromes, call CODE (2633). For all other transfers, call or CME Opportunities: Live and Online Cleveland Clinic s Center for Continuing Education s website, clevelandclinicmeded.com, offers hundreds of convenient, complimentary learning opportunities, from webcasts and podcasts to a host of medical publications including the Disease Management Project Online Medical Textbook, with more than 150 chapters. The site also offers a schedule of live CME courses, including international summits that focus on key areas of translational research. Many live CME courses are hosted in Cleveland, an economical option for business travel. Physicians can manage their CME credits by using the mycme Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe. Digestive Disease Institute 53

56 staffed beds, an education institute and a research institute. clevelandclinic.org.