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Synoptic operative reporting in cancer surgery: A scoping review

Published:January 07, 2023DOI:https://doi.org/10.1016/j.amjsurg.2023.01.003

      Highlights

      • Operative reporting has been studied most frequently in rectal and breast cancer.
      • Synoptic operative reports have better overall reporting completeness.
      • Most cancer elements are reported more consistently in synoptic operative reports.
      • Transition to synoptic operative reporting may improve quality of cancer care.

      Abstract

      Background

      Narrative operative reports (NOR) are important for cancer management but often lack key information. This review investigated the efficacy of synoptic operative reports (SORs) for cancer operations compared to NORs.

      Methods

      A database search included published studies up to October 31, 2021. Overall report completeness and reporting frequencies of cancer elements were descriptively compared between NORs and SORs.

      Results

      Among 4353 studies, 32 were included. 47% of studies compared NORs to SORs. Overall completeness favored SORs (80 ± 19%) over NORs (47 ± 18%, p < 0.001). Essential cancer operative report elements including tumor location (NOR: 51 ± 28%, SOR: 89 ± 11%, p < 0.001), presence of metastases (NOR: 36 ± 33%, SOR: 96 ± 5%, p < 0.001), and final resection margins (NOR: 39 ± 30%, SOR: 87 ± 17%, p < 0.001) demonstrated higher mean reporting frequencies in SORs.

      Conclusion

      Overall completeness and reporting of cancer elements were superior in SORs. Although standardization of SORs requires further research, transition from NORs to SORs may improve the quality of postoperative cancer care.

      Graphical abstract

      Keywords

      Abbreviations:

      NOR (narrative operative report), SORs (synoptic operative report), NR (narrative reporting), SR (synoptic reporting), RFS (recurrence free survival), CAP (College of American Pathologists), ACR (American College of Radiology), TI-RADS (Thyroid Imaging Reporting and Data System), BI-RADS (Breast Imaging Reporting and Data System), ACS (American College of Surgeons), QI (quality indicator), EMR (electronic medical record)
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