Identification of patients eligible for discharge within 48 h of colorectal resection

Early discharge after enhanced recovery rectal resection does not increase emergency department visits and readmissions: a single institution analysis

BACKGROUND

Same-day discharge after colectomy in enhanced recovery pathways has been shown to be feasible. It is not clear how early patients with rectal resections may be safely discharged. The study aim was to determine if patients discharged ≤ 3 days after rectal resections are associated with increased rates of emergency department (ED) visits and hospital readmissions.

METHODS

Retrospective analysis of enhanced recovery low anterior resection, abdominoperineal resection, and proctocolectomy patients in a prospectively maintained single institution colorectal surgery database from 01/01/2018 to 07/15/2022. Clinic visits were scheduled within 4-7 days and at 30 days after discharge, and every 1-2 weeks for stoma patients until no longer needed. Logistic regression models were used to analyze the association of discharge on postoperative days (POD)-1-3, POD-4-5, and POD ≥ 6 days with incidence of ED visits and readmissions.

RESULTS

A total of 118 patients met inclusion criteria, 76 with stomas. Median postoperative length of stay was 5 [IQR 6.5] days. Mean age was 58.6 years; 59.3% were ASA-3; and 69.5% had a minimally invasive surgical approach. ED visits were not significantly different between discharge-day groups (p = 0.096). No patients were discharged same-day, one without a stoma was discharged on POD-1, ten patients (2 with stomas) on POD-2, and twenty-four patients (13 with stomas) on POD-3. ED visits were lowest for the POD-1-3 group (14.3%) but not significantly different than later discharge groups (p = 0.166). Readmission rate was also lowest for the POD-1-3 group (11.4%) and also not significantly different than later discharge groups (p = 0.261) and this was confirmed with logistic regression. Complication rate was lowest in the POD-1-3 group (p < 0.001).

CONCLUSION

Early discharge after enhanced recovery partial or complete proctectomy is not associated with increased ED visits and readmissions. Follow up studies should identify post-discharge resources that allow safe early discharge and that may be standardized and generalizable.

Perioperative Fluid Management in Colorectal Surgery: Institutional Approach to Standardized Practice

The present review discusses restrictive perioperative fluid protocols within enhanced recovery after surgery (ERAS) pathways. Standardized definitions of a restrictive or liberal fluid regimen are lacking since they depend on conflicting evidence, institutional protocols, and personal preferences. Challenges related to restrictive fluid protocols are related to proper patient selection within standardized ERAS protocols. On the other hand, invasive goal-directed fluid therapy (GDFT) is reserved for more challenging disease presentations and polymorbid and frail patients. While the perfusion rate (mL/kg/h) appears less predictive for postoperative outcomes, the authors identified critical thresholds related to total intravenous fluids and weight gain. These thresholds are discussed within the available evidence. The authors aim to introduce their institutional approach to standardized practice.

The Postoperative Utilization of Intensive Care Beds After Visceral Surgery Procedures

BACKGROUND

The necessary number of intensive care beds has been under debate in recent years. This study aims to provide a descriptive analysis of postoperative intensive care for visceral surgery patients based on three indicator procedures, with particular attention to the frequency and duration of intensive care among these patients, trends in the occupancy of intensive care units, and the course during the COVID-19 pandemic.

METHODS

Routine data from inpatient cases of the Helios group (24 888 cases from 71 acute care hospitals) from 01.01.2016 to 31.12.2021 were analyzed retrospectively. The indicator procedures were colorectal resection, surgery for gastric carcinoma, and left pancreatic resection.

RESULTS

Routine data reveal a decline in the utilization of intensive care by these patients over the years, e.g., after colorectal resection, from 84.2% in 2016 to 63.1% in 2021. The percentage of patients requiring mechanical ventilation declined to a small extent as well (2016: 10.3%; 2021: 8.9%). In-hospital mortality remained stable in the range of 4.1% to 5.2%. The number of gastric carcinomas operated on fell from 355 in 2016 to 239 in 2021, while the number of left pancreatic resections remained stable in the range of 147 to 172 per year.

CONCLUSION

In the hospitals studied, visceral surgery patients still commonly undergo intensive care postoperatively, at a rate that is declining slowly over the years. No adjustments were made for age, sex, or Elixhauser comorbidity index.

Verbreitung von Fast-Track-Konzepten in Deutschland

Hintergrund

Fast-Track-Konzepte haben die perioperative Betreuung von Patienten in den letzten 30 Jahren grundlegend verändert. Evidenz für diese Konzepte ist ausreichend vorhanden.

Ziel der Arbeit

Ziel dieses Artikels war es, die Verbreitung von Fast-Track-Konzepten in Deutschland anhand von Routinedaten zu evaluieren.

Material und Methoden

Es wurde eine retrospektive Analyse aller kolorektalen Resektionen der Helios-Kliniken der Jahre 2016 bis 2021 durchgeführt. Diese wurden bezüglich Krankenhausverweildauer, Intensivbelegung, Beatmungsanteil, Mortalität, Komplikationsrate und Zugangsweg analysiert.

Ergebnisse und Diskussion

Eine intensivmedizinische Belegung nach kolorektalen Resektionen ist in Deutschland weiterhin die Regel. Insbesondere bei onkologischen kolorektalen Resektionen werden nach wie vor zwei Drittel der Patienten perioperativ intensivmedizinisch betreut. Die stationäre Liegedauer bei kolorektalen Resektionen ist im internationalen Vergleich weiter überdurchschnittlich lang und auch über die letzten Jahre nur langsam rückläufig (z. B. Kolonkarzinom 2016: 18,6 ± 11,9 Tage/2021: 13,8 ± 9,3). Der Anteil offen-chirurgischer kolorektaler Eingriffe ist rückläufig, macht aber auch 30 Jahre nach Einführung der Laparoskopie einen relevanten Anteil aus (z. B. Kolonkarzinom 2016: 71,10 %/2021: 56,44 %). Die Versorgung von Patienten mit kolorektalen Resektionen scheint demnach weiterhin nicht nach Fast-Track-Prinzipen umgesetzt zu sein.

Impact of enhanced recovery protocols after pancreatoduodenectomy: meta-analysis

BACKGROUND

This individual-patient data meta-analysis investigated the effects of enhanced recovery after surgery (ERAS) protocols compared with conventional care on postoperative outcomes in patients undergoing pancreatoduodenectomy.

METHODS

The Cochrane Library, MEDLINE, Embase, Scopus, and Web of Science were searched systematically for articles reporting outcomes of ERAS after pancreatoduodenectomy published up to August 2020. Comparative studies were included. Main outcomes were postoperative functional recovery elements, postoperative morbidity, duration of hospital stay, and readmission.

RESULTS

Individual-patient data were obtained from 17 of 31 eligible studies comprising 3108 patients. Time to liquid (mean difference (MD) -3.23 (95 per cent c.i. -4.62 to -1.85) days; P < 0.001) and solid (-3.84 (-5.09 to -2.60) days; P < 0.001) intake, time to passage of first stool (MD -1.38 (-1.82 to -0.94) days; P < 0.001) and time to removal of the nasogastric tube (3.03 (-4.87 to -1.18) days; P = 0.001) were reduced with ERAS. ERAS was associated with lower overall morbidity (risk difference (RD) -0.04, 95 per cent c.i. -0.08 to -0.01; P = 0.015), less delayed gastric emptying (RD -0.11, -0.22 to -0.01; P = 0.039) and a shorter duration of hospital stay (MD -2.33 (-2.98 to -1.69) days; P < 0.001) without a higher readmission rate.

CONCLUSION

ERAS improved postoperative outcome after pancreatoduodenectomy. Implementation should be encouraged.

OUP accepted manuscript

Background

Early postoperative discharge after colorectal surgery within the enhanced recovery after surgery (ERAS) guidelines has been demonstrated to be safe, although its applicability has not been universal. The primary aim of this study was to identify the predictors of early discharge and readiness for discharge in a study population.

Methods

Early discharge was defined as discharge occurring in 72 h or less after surgery. The characteristics and clinical outcomes of the patients in the early and non-early discharge groups were compared, and variables associated with early discharge were identified. Additionally, independent variables associated with the readiness for discharge within 48 h were evaluated.

Results

Of 965 patients who underwent colorectal surgery between January 2015 and July 2020, 788 were included in this study. No differences in readmission, reoperation, or 30-day mortality were observed between the early and non-early discharge groups. Both early discharge and readiness for discharge had a positive association with adherence to 80 per cent or more of the ERAS items and a negative association with the female sex, duration of surgery, drain positioning, and postoperative complications.

Conclusion

Early discharge after colorectal surgery is safe and feasible, and is not associated with a high risk of readmission or reoperation. Discharge at 48 h can be reliably predicted in a subset of patients. Future studies should collect prospective data on early discharge related to safety, as well as patients’ expectations, possible organizational issues, and effective costs reduction in Italian clinical practice.

Development and validation of a prediction score for safe outpatient colorectal resections

BACKGROUND

Avoiding unnecessary inpatient stay may decrease hospital-acquired complications and costs while increasing patient satisfaction. This study aimed to develop and validate a score to identify patients eligible for safe same-day discharge after colorectal resections.

METHODS

This bi-institutional retrospective cohort study included consecutive patients undergoing elective colon and rectal resections (2011-2018) for benign and malignant indications. Two multivariable logistic models were developed based on demographic and surgical risk factors to predict a combined endpoint (ileus, anastomotic leak, intra-abdominal abscess, and readmission). Development and validation datasets were randomly sampled from the entire cohort. Areas under the receiver operating characteristic curves (AUC) were evaluated, and Hosmer-Lemeshow goodness-of-fit tests were used to assess validation model fit.

RESULTS

Of 5,389 patients, 1,182 (21.9%) experienced at least one complication of the combined endpoint. Male gender, open surgery, ASA ≥3, wound class ≥3, ileostomy, surgical duration >3 hours, and perioperative IV fluids >3 L all had significantly greater odds of the combined endpoint in the parsimonious multivariable model (all P < .05). The reduced model considering only the 4 variables with the highest OR (>1.5) contained open surgery, ASA ≥3, wound class ≥3, and surgical duration ≥3 hours as predictors (all P < .05, AUC of 0.65; 95% CI 0.63, 0.68). Both the parsimonious model and the reduced model demonstrated no lack of fit in the validation cohort.

CONCLUSION

The suggested score composed of preand intraoperative items may help physicians decide on patients' same-day discharge after colorectal resection.

Preoperative risk factors for major postoperative complications after complex gastrointestinal cancer surgery: A systematic review

Patients undergoing complex gastrointestinal surgery are at high risk of major postoperative complications (e.g., anastomotic leakage, sepsis), classified as Clavien-Dindo (CD) ≥ IIIa. Identification of preoperative risk factors can lead to the identification of high-risk patients. These risk factors can also be used to design personalized perioperative care. This systematic review focuses on the identification of these factors. The Medline and Embase databases were searched for prospective, retrospective cohort studies and randomized controlled trials investigating the effect of risk factors on the occurrence of major postoperative complications and/or mortality after complex gastrointestinal cancer surgery. Risk of bias was assessed using the Quality in Prognostic Studies tool. The level of evidence was graded based on the number of studies reporting a significant association between risk factors and major complications. A total of 207 eligible studies were retrieved, identifying 33 risk factors for major postoperative complications and 13 preoperative laboratory results associated with postoperative complications. The present systematic review provides a comprehensive overview of preoperative risk factors associated with major postoperative complications. A wide range of risk factors are amenable to actions in perioperative care and prehabilitation programs, which may lead to improved outcomes for high-risk patients. Additionally, the knowledge of this study is important for benchmarking surgical outcomes.

Feasibility assessment of outpatient colorectal resections at a tertiary referral center

PURPOSE

Enhanced Recovery After Surgery (ERAS) protocols, particularly when paired with advanced laparoscopy, have reduced recovery time following colorectal procedures. The aim of this study was to determine if length of stay (LOS) could be reduced to an overnight observation stay (< 24 h) with comparable perioperative morbidity. The secondary aim was to establish predictive factors contributing to early discharge.

METHODS

This is a retrospective cohort study of all colectomies at a tertiary care center between January 2016 and January 2019. Inclusion criteria included all colorectal resections with varying surgical approaches. Patients underwent a standardized ERAS protocol. A logistical regression model was conducted for predictive factors.

RESULTS

Three hundred sixty patients were included (55.3% female). Of these, 78 (21.7%) patients were discharged within < 24 h and 112 (31.1%) were discharged within 24-48 h. The remainder comprised the > 48 h group. Age differed significantly between the < 24 h and 24-48 h groups (p < 0.0001). Patients discharged within 24 h were younger (59.4 ± 12.3 years), had a lower CCI score (3.1; p = 0.0026), and lower ASA class (p < 0.0001). Emergency department visits (p = 0.3329) and readmissions (p = 0.6453) prior to POD 30 remained comparable among all groups. Younger age, low ASA, and minimally invasive surgical approach all contributed to ultra-fast discharge.

CONCLUSION

ERAS protocols may allow for discharge within 24 h following a major colorectal resection, all with low perioperative morbidity and mortality. The predictive factors for discharge within 24 h include a low ASA (I or II), and a minimally invasive surgical approach.

Epidural analgesia for postoperative pain: Improving outcomes or adding risks?

Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits.

Monitoring an Ongoing Enhanced Recovery After Surgery (ERAS) Program: Adherence Improves Clinical Outcomes in a Comparison of Three Thousand Colorectal Cases

AIM

In 2014, Memorial Sloan Kettering Cancer Center was identified as an outlier for increased length of stay (LOS) after colorectal surgery. We subsequently implemented a comprehensive Enhanced Recovery After Surgery (ERAS) program in January 2016, which is continually monitored to target areas for improvement. The primary aim of this study was to evaluate the impact of a newly established ERAS program in a high-volume colorectal center over time.

METHOD

This was a retrospective cohort study, comparing 3000 sequential cancer patients who underwent elective colorectal surgery before and after ERAS implementation. Patients were divided into three groups (Pre-, Early, and Late ERAS). Adherence to ERAS process measures and outcomes (LOS, complications, and 30-day readmission) were compared among the three time periods.

RESULTS

Adherence to ERAS metrics significantly increased over time, from a median of 25% Pre-ERAS to 67% Early and 75% Late ERAS (p < 0.0001). Mean LOS decreased from 5.2 days Pre-ERAS to 4.5 Early and 4.0 Late ERAS (p < 0.0001). There were no differences in rates of complications or readmissions, and patients with shorter LOS had lower readmission rates. With ERAS, the readmission rate was 4.4% for patients discharged within 3 days, versus >10% for LOS ≥5 days (p < 0.0001).

CONCLUSION

Initiation of an ERAS program at a high-volume colorectal center was associated with decreased LOS, without increasing morbidity. Increased ERAS adherence was associated with a further decrease in LOS. Multidisciplinary monitoring to promote protocol adherence is necessary for maintaining a safe and effective ERAS program.