Twenty-Three-Hour-Stay Colectomy Without Increased Readmissions: An Analysis of 1905 Cases from the National Surgical Quality Improvement Program

Evaluating Outcomes of Same Day Discharge After Minimally Invasive Colectomy: A Nationwide Analysis

BackgroundAdvances in Enhanced Recovery After Colectomy protocols have enabled same day discharge (SDD) in some patients. Current literature is limited to single institutions limiting generalizability. We employed a nationally-representative dataset to compare outcomes between SDD patients and patients with a short-term hospital stay (discharged on postoperative day 1 or 2).MethodsWe conducted a retrospective study using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) Targeted Colectomy Participant User Files (2017-2021). We included patients ≥18 years who underwent elective minimally invasive colectomy. We excluded patients with severe comorbid conditions or in-hospital complications. We performed a 1:1 propensity-match adjusting for patient, diagnosis, and procedure- type characteristics. Our primary outcome was 30-day readmission and secondary outcome was post-discharge complications.ResultsWe identified 22,482 patients, 740 (3.3%) of which were SDD patients. A higher proportion of patients with SDD underwent right colectomy (76.4% vs36.4%, P < 0.001) and carried a diagnosis of a benign neoplasm (53.0% vs18.1%, P < 0.001). After propensity matching there was no significant difference in the rate of 30-day readmission between the 2 groups (3.4% vs4.7%; P = 0.23). Additionally, there was no significant difference in rates of anastomotic leak (0.7% vs0.8%; P = 0.58) or colonic ileus (1.4% vs1.8%; P = 0.58). Post-discharge bleeding complications were higher in SDD patients (0.5% vs0%; P = 0.045).ConclusionsSDD following minimally invasive colectomy is not associated with higher readmission, anastomotic leak, or SSI when compared to patients discharged on postoperative day 1/2. SDD after minimally invasive colectomy may be considered for patients without severe comorbid conditions.

Readmission and Adoption of Early Discharge After Colectomy Using ACS-NSQIP: Is It Time for Widespread Adoption?

INTRODUCTION

The timing of post-operative discharge following colectomy procedures remains a subject of debate among colorectal surgeons. Prior studies have demonstrated the safety and adoption of early discharge within 24 h after elective colectomy in carefully selected patients.

METHODS

This retrospective cohort study utilizing data from the American COllege of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2012 to 2021. Adult patients undergoing elective partial colectomy with primary anastomosis and documented length of stay were included. Patients were stratified into early (< 24) and non early (≥24 h) discharge groups. Propensity score matching was used to control for baseline demographics and non-modifiable risk factors. Primary outcomes included 30-day readmission rates and adoption trends of early discharge over time.

RESULTS

A total of 282,037 patients met inclusion criteria of which 6364 (2.3%) were discharged within 24 h. On propensity score matching the early discharge cohort had a statistically significantly lower rate of readmission (5.5% versus 7.3%, P < 0.001). Additionally, the early discharge group had a significantly reduced rate of anastomotic leak (1.0 versus 2.6%), ileus (2.0% versus 7.6%), and rate of reoperation (1.2% versus 4.0%) (P < 0.001). The proportion of early discharge colectomies increased from 0.8% in 2012 to 3.6% in 2021 (P < 0.001).

CONCLUSIONS

In carefully selected patients, early discharge after colectomy with primary anastomosis does not increase the risk of readmission, reoperation, or 30-d complication rates. Furthermore, the increasing trend in utilization of early discharge after colectomy suggests an increasing acceptance of this practice, though it remains a minority of all colectomies performed among institutions participating in ACS-NSQIP.

Feasibility of an < 24 h discharge pathway with tele-monitoring after elective colectomies: a pilot study

INTRODUCTION

Implementation of enhanced recovery after surgery principles has led to exploration of ambulatory pathways in surgery, including gastrointestinal surgery. However, implementation of ambulatory pathways after colorectal surgery has not been established yet. Previous studies suggest that discharge within 24 h in colorectal surgery is only possible with a clear protocol and careful patient selection.

METHODS

Single center prospective feasibility pilot study of thirty patients in one large non-academic teaching hospital in the Netherlands. Patients were included if they were between 18 and 80 years old, underwent elective minimal invasive colonic resection with anastomosis, had a ASA-score of I or II, fully understood the procedure, had a person at home the first 4 days after surgery and lived within 30 min travel radius to the hospital. Exclusion criteria were cT4 tumours, multi-visceral resections, insulin-dependent diabetes, anti-coagulants which required perioperative bridging, and perioperative complications. Patients followed a pathway with discharge within 24 h postoperatively and were monitored by a tele-monitoring smartphone application after discharge.

RESULTS

Thirty patients were included and twenty-one patients (70%) fulfilled discharge criteria within 24 h after surgery. Six (20%) patients were readmitted within 30 days. Complications occurred in six (20%) patients, which was classified as Clavien-Dindo ≥ 3 complication in one (3%) patient. Patients and health care provider satisfaction was high.

CONCLUSION

Findings of this study support the feasibility and safety of an early discharge protocol with tele-monitoring after minimal invasive colonic resection. Satisfaction of patients and health care providers was high.

National trends and costs of same day discharge in patients undergoing elective minimally invasive colectomy

BACKGROUND

Enhanced Recovery Pathways (ERPs) have enabled safe same day discharge (SDD) of select patients after elective minimally invasive colectomy. We aimed to analyse the financial impact of SDD in these cases.

METHODS

We queried the Nationwide Readmission Database (2016-2019) and included patients with a hospital length of stay ≤2 days after minimally invasive elective colectomy. Propensity score matched pairs of patients discharged on the day of the operation and those discharged on post operative day 1 or 2 were compared. Our primary outcome was the combined cost of hospitalization and readmission.

RESULTS

SDD patients had lower comorbidity (33 ​% vs 21 ​%) and illness severity (79 ​% vs 63 ​%), more Medicare insurance (44 ​% vs 38 ​%), and more benign neoplasms (52 ​% vs 17 ​%). Most SDD patients underwent right colectomy (89 ​%). Across 647 matched pairs, total cost was significantly lower in SDD patients ($8000 vs. $12,900; p ​< ​0.001) due to cheaper index hospitalizations. No difference in readmission rates or costs emerged.

CONCLUSION

SDD reduced costs of index hospitalization and may be cost-effective in a select cohort of healthier patients.

Accelerated enhanced recovery after colon cancer surgery with discharge within one day after surgery: a systematic review

BACKGROUND

Recent studies have demonstrated that accelerated enhanced recovery after colorectal surgery is feasible for specific patient populations. The accelerated enhanced recovery protocols (ERP) tend to vary, and the majority of studies included a small study population. This hampers defining the optimal protocol and establishing the potential benefits. This systematic review aimed to determine the effect of accelerated ERPs with intended discharge within one day after surgery.

METHODS

PubMed (MEDLINE), Embase, Cochrane and Web of Science databases were searched using the following search terms: colon cancer, colon surgery, accelerated recovery, fast track recovery, enhanced recovery after surgery. Clinical trials published between January 2005 - February 2023, written in English or Dutch comparing accelerated ERPs to Enhanced Recovery After Surgery (ERAS) care for adult patients undergoing elective laparoscopic or robotic surgery for colon cancer were eligible for inclusion.

RESULTS

Thirteen studies, including one RCT were included. Accelerated ERPs after colorectal surgery was possible as LOS was shorter; 14 h to 3.4 days, and complication rate varied from 0-35.7% and readmission rate was 0-17% in the accelerated ERP groups. Risk of bias was serious or critical in most of the included studies.

CONCLUSIONS

Accelerated ERPs may not yet be considered the new standard of care as the current data is heterogenous, and data on important outcome measures is scarce. Nonetheless, the decreased LOS suggests that accelerated recovery is possible for selected patients. In addition, the complication and readmission rates were comparable to ERAS care, suggesting that accelerated recovery could be safe.

Can Colorectal Surgery Be Performed as an Outpatient Surgery?

The potential to discharge patients safely within the same day after colorectal surgery has developed over time with concurrent advances in concepts of enhanced recovery pathways, along with minimally invasive techniques available to surgeons. The advent of planned same-day discharges after elective colectomy is made possible by research establishing improved length of stay with minimal morbidity in patients undergoing minimally invasive surgery and especially minimally invasive surgery in the setting of an enhanced recovery after surgery (ERAS) protocol. In tracing the timeline of research and development of knowledge in this setting, the safety of outpatient colorectal surgery can be established.

Safety and Feasibility of ≤24-h Short-Stay Right Colectomies for Primary Colon Cancer

BACKGROUND

Hospital length of stay (LOS) has been used as a surgical quality metric. This study seeks to determine the safety and feasibility of right colectomy as a ≤24-h short-stay procedure for colon cancer patients.

METHODS

This was a retrospective cohort study using the ACS-NSQIP database and its Procedure Targeted Colectomy database (2012-2020). Adult patients with colon cancer who underwent right colectomies were identified. Patients were categorized into LOS  ≤1 day (≤24-h short-stay), LOS 2-4 days, LOS 5-6 days, and LOS ≥7 days groups. Primary outcomes were 30-day overall and serious morbidity. Secondary outcomes were 30-day mortality, readmission, and anastomotic leak. The association between LOS and overall and serious morbidity was assessed using multivariable logistic regression.

RESULTS

19,401 adult patients were identified, with 371 patients (1.9%) undergoing short-stay right colectomies. Patients undergoing short-stay surgery were generally younger with fewer comorbidities. Overall morbidity for the short-stay group was 6.5%, compared to 11.3%, 23.4%, and 42.0% for LOS 2-4 days, LOS 5-6 days, and LOS ≥7 days groups, respectively (p < 0.001). There were no differences in anastomotic leak, mortality, and readmission rates in the short-stay group compared to patients with LOS 2-4 days. Patients with LOS 2-4 days had increased odds of overall morbidity (OR 1.71, 95% CI 1.10-2.65, p = 0.016) compared to patients with short-stay but no differences in odds of serious morbidity (OR 1.20, 95% CI 0.61-2.36, p = 0.590).

CONCLUSIONS

≤24-h short-stay right colectomy is safe and feasible for a highly-select group of colon cancer patients. Optimizing patients preoperatively and implementing targeted readmission prevention strategies may aid patient selection.

Factors Associated with Early Discharge after Non-Emergent Right Colectomy for Colon Cancer: A NSQIP Analysis

The National Surgical Quality Improvement Project (NSQIP) dataset was used to identify perioperative variables associated with the length of stay (LOS) and early discharge among cancer patients undergoing colectomy. Patients who underwent non-emergent right colectomy for colon cancer from 2012 to 2019 were identified from the NSQIP and colectomy-targeted databases. Postoperative LOS was analyzed based on postoperative day (POD) of discharge, with patients grouped into Early Discharge (POD 0-2), Standard Discharge (POD 3-5), or Late Discharge (POD ≥ 6) cohorts. Multivariable ordinal logistic regression was performed to identify risk factors associated with early discharge. The NSQIP query yielded 26,072 patients: 3684 (14%) in the Early Discharge, 13,414 (52%) in the Standard Discharge, and 8974 (34%) in the Late Discharge cohorts. The median LOS was 4.0 days (IQR: 3.0-7.0). Thirty-day readmission rates were 7% for Early Discharge, 8% for Standard Discharge, and 12% for Late Discharge. On multivariable regression analysis, risk factors significantly associated with a shorter LOS included independent functional status, minimally invasive approach, and absence of ostomy or additional bowel resection (all p < 0.001). Perioperative variables can be used to develop a model to identify patients eligible for early discharge after right colectomy for colon cancer. Efforts to decrease the overall median length of stay should focus on optimization of modifiable risk factors.

Accelerated 23-h enhanced recovery protocol for colon surgery: the CHASE-study

The introduction of the Enhanced Recovery After Surgery (ERAS) program has radically improved postoperative outcomes in colorectal surgery. Optimization of ERAS program to an accelerated recovery program may further improve these said outcomes. This single-center, prospective study investigated the feasibility and safety of a 23-h accelerated enhanced recovery protocol (ERP) for colorectal cancer patients (ASA I-II) undergoing elective laparoscopic surgery. The 23-h accelerated ERP consisted of adjustments in pre-, peri- and postoperative care; this was called the CHASE-protocol. This group was compared to a retrospective cohort of colorectal cancer patients who received standard ERAS care. Patients were discharged within 23 h after surgery if they met the discharge criteria. Primary outcome was the rate of the successful discharge within 23 h. Successful discharge within the CHASE-cohort was realized in 33 out of the 41 included patients (80.5%). Compared to the retrospective cohort (n = 75), length of stay was significantly shorter in the CHASE-cohort (p = 0.000), and the readmission rate was higher (p = 0.051). Complication rate was similar, severe complications were observed less frequently in the CHASE-cohort (4.9% vs. 8.0%). Findings from this study support the feasibility and safety of the accelerated 23-h accelerated ERP with the CHASE-protocol in selected patients.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation

BACKGROUND

As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay.

METHODS

Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes.

RESULTS

Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing.

CONCLUSIONS

The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

Reduced Opioid Use and Prescribing in a Same Day Discharge Pilot Enhanced Recovery Program for Elective Minimally Invasive Colorectal Surgical Procedures During the COVID-19 Pandemic

Purpose

Enhanced recovery pathways (ERPs) are associated with reduced complications and length of stay. The validation of the I-FEED scoring system, advances in perioperative anesthesia, multimodal analgesia, and telehealth remote monitoring have resulted in further evolution of ERPs setting the stage for same day discharge (SDD). Pioneers and early adopters have demonstrated the safety and feasibility of SDD programs. The aim of this study is to evaluate the impact of a pilot SDD ERP on patient self-reported pain scoring and narcotic usage.

Methods

A quality improvement pilot program was conducted to assess the impact of a SDD ERP on post-operative pain score reporting and opioid use in healthy patients undergoing elective colorectal surgery as an alternative to post-operative hospitalization during the COVID-19 pandemic (May 2020-December 2021). Patients were monitored remotely with daily telephone visits on POD 1-7 assessing the following variables: I-FEED score, pain score, pain management, bowel function, dietary advancement, any complications, and/or re-admissions.

Results

Thirty-seven patients met the highly selective eligibility criteria for “healthy patient, healthy anastomosis.” SDD occurred in 70%. The remaining 30% were discharged on POD 1. Mean total narcotic usage was 5.2 tablets of 5 mg oxycodone despite relatively high reported pain scores.

Conclusions

In our initial experience, SDD is associated with significantly lower patient narcotic utilization for postoperative pain management than hypothesized. This pilot SDD program resulted in a change in clinical practice with reduction of prescribed discharge oxycodone 5 mg quantity from #40 to #10 tablets.