Early Discharge After Colorectal Resection: The Positive Impact of an Enhanced Recovery Program on a Rural Colorectal Surgery Service

Impact of enhanced recovery program on clinical outcomes after elective colorectal surgery in a rural hospital. A single center experience

BACKGROUND

The main purpose was to determine the impact on postoperative outcomes of a standardized enhanced recovery program (ERP) for elective colorectal surgery in a rural hospital.

METHODS

A prospective series of patients (N = 80) undergoing elective colorectal resection completing a standardized ERP protocol in 2018-2020 (ERP group) was compared to patients (N = 80) operated at the same rural hospital in 2013-2015 (pre-ERP group), before the implementation of the program. The exclusion criteria for both groups were: ASA score IV, TNM stage IV, inflammatory bowel disease, emergency surgery, and rectal cancer. The primary outcome was hospital length of stay (LoS) which was used as an estimate of functional recovery. Secondary outcomes included 30-day readmission and mortality rates as well as associated factors with both postoperative complications and prolonged hospital LoS.

RESULTS

Baseline characteristics were comparable in both groups. The median adherence to ERP protocol elements was 68 % versus 12 % in the retrospective control group. The median hospital LoS in the ERP-group was significantly lower than in the pre-ERP group (5 vs. 10 days) with no increase in 30-day readmission and mortality rates. The Body Mass Index ≥30 and the traditional peri-operative protocol were the associated factors to postoperative complications, while following a traditional peri-operative protocol was the only factor associated with a prolonged hospital LoS (p < 0.0001).

CONCLUSIONS

Although limited hospital resources are perceived as a barrier to ERP implementation, the current experience demonstrates how adopting an ERP program in a rural area is feasible and effective, despite it requires greater effort.

Enhanced recovery after surgery reduces length of stay after colorectal surgery in a small rural hospital in Ontario

Introduction

Enhanced recovery after surgery (ERAS) programmes include pre-operative, intraoperative and post-operative clinical pathways to improve quality of patient care while reducing length of stay (LOS) and readmission. This study assessed the feasibility and outcomes of an ERAS protocol for colorectal surgery implemented over 2 years in a small, resource-challenged rural hospital.

Methods

A prospective cohort study used retrospectively matched controls to assess the effect of ERAS on LOS in patients undergoing colorectal surgery in a small rural hospital in northern Ontario, Canada. ERAS patients were matched to two patients in the control group based on diagnosis, age and gender. Patients had open or laparoscopic colorectal surgeries, with those in the intervention group treated per ERAS protocol and given instructions on pre- and post-operative self-care.

Results

Most of the 47 ERAS patients recruited to the study reported adherence to ERAS protocols before surgery. Adherence to protocol was strongest for chewing gum in the days after surgery. Most patients were sitting in a chair for their afternoon meal by the 1st day and most were walking down the hallway by the 2nd day. The control group had significantly higher (P < 0.001) malignant neoplasm of the colon (C18, 69% vs. 35%) and significantly lower malignant neoplasm of the rectum (C20, 0% vs. 5%). The control group had an average ln-transformed LOS that was significantly longer (exponentiated as 1.7 days) than ERAS patients (t-test, P < 0.001).

Conclusion

This study found that ERAS could be implemented in a small rural hospital and provided evidence for a reduced LOS of approximately 2 days.

Proposal and Validation of a New Classification of Surgical Outcomes after Colorectal Resections within an Enhanced Recovery Programme

Background

Advantages of Enhanced Recovery (ER) programmes in colorectal surgery have already been demonstrated, but heterogeneity exists with respect to the choice of compared outcomes. A comprehensive classification aimed at standardizing the reporting of surgical outcomes has been proposed and validated.

Method

Clinical variables of 231 patients who underwent colorectal resections within an ER programme from 2013–2018 were analysed. Their outcomes have been reported according to a new classification in 5 classes and 11 subclasses. Prognostic variables have been identified.

Results

Seventy-nine patients (34.2%) had an optimal class 1 outcome. Almost half of the patients had an uneventful recovery after being discharged after day 4 (2a). Only two patients (0.9%) were discharged early and then readmitted for a minor ailment (2b). Total morbidity was 12.6% (3a–5). Perioperative mortality was 2.6% (5). Young age, laparoscopic resection, and years of experience with ER have been identified as independent prognostic factors towards a totally positive outcome.

Conclusions

The proposed outcome classification is a simple and objective tool to report the surgical outcome in clinical studies. Its implementation seems to be appropriate, in particular, in the field of ER protocols in colorectal surgery, but it can have a wider application in any other surgical subspeciality.

Rural context, single institution prospective outcomes after enhanced recovery colorectal surgery protocol implementation

Background

Rural hospitals face unique challenges to adopting Enhanced Recovery protocols after colorectal surgical procedures. There are few examples of successful implementation in the United States, and fewer yet of prospective, outcomes-based trials.

Methods

This study drew data from elective bowel resection prospectively collected, retrospectively analyzed cases 2 years prior (n = 214) and 3 years after (n = 224) implementing an ERAS protocol at a small, rural health network in upstate New York. Primary outcomes were cost, length-of-stay, readmission rate, and complications.

Results

The implementation required changes and buy-in at multiple levels of the institution. There was a statistically significant reduction in mean length of stay (6.9 versus 5.1 days) and per-patient savings to hospital ($3000) after implementation of ERAS protocol. There was no significant change in rate of 30-day readmissions or complications.

Conclusions

The authors conclude that for rural-specific barriers to implementation of Enhanced Recovery protocols there are specific organizational strategies that can ultimately yield sustainable endpoints.

Surgical Risk and Pathological Results of Emergency Resection in the Treatment of Acutely Obstructing Colorectal Cancers: A Retrospective Cohort Study

Purpose

The treatment of acutely obstructing colorectal cancers is still a matter of debate. The prevailing opinion is that an immediate resection should be performed whenever possible. This study sought to determine whether immediate resection is safe and oncologically valid.

Methods

We completed a retrospective 2-center cohort study using the medical records of patients admitted for acutely obstructing colorectal cancer under the care of the Colorectal Team, Noble’s Hospital, Isle of Man, and the Emergency Surgery Unit, Umberto I University Hospital, Rome, from March 2013 to May 2017. The primary endpoints were 90-day mortality and morbidity, reoperation rate, and length of stay. The secondary endpoints were status of margins, number of lymph nodes retrieved, and the rate of adequate nodal harvest.

Results

Sixty-three patients were retrospectively enrolled in the study. Mortality was associated with age > 80 years and Dukes B tumors. The length of hospital stay was shorter in patients who had their resection less than 24 hours from their admission, in those who had laparoscopic resection and in those with distal tumors. The number of lymph nodes retrieved and rate of R0 resections were similar to those reported in elective colorectal surgery and were greater in laparoscopic resections and in patients operated on within 24 hours, respectively.

Conclusion

Immediate resection is a safe and reliable option in patients with acutely obstructing colorectal cancer.

The impact of complications on a programme of enhanced recovery in colorectal surgery

Background

The advantages of Enhanced Recovery (ER) programmes are well known, in terms of improved overall experience of the patients, which associates with low morbidity and reduced length of stay. As a result, the pattern of morbidity is changing and some patients may develop complications after discharge. Aim of this work was to evaluate the impact of morbidity and related outcomes such as unplanned readmission and reoperation rate on an ER programme in colorectal surgery.

Methods

Prospectively collected clinical data of patients who underwent colorectal resection have been retrospectively analysed. Endpoints were: 90-day mortality and morbidity, length of hospital stay (LOS) and rate of unplanned readmissions and reoperations.

Results

Mortality and morbidity did not change in the analysed period, but LOS reduced significantly. Main determinant of postoperative LOS was the type of surgical approach, laparoscopy being associated with earlier discharge. LOS was longer in patients who developed complications. Morbidity and reoperation rate were significantly higher in patients discharged after day 4. Majority of complications happened in patients who were still in the hospital. However, the few patients who developed complications after discharge did not have a worse outcome if compared to those who had complications in hospital.

Conclusions

ER protocols must become integral part of the perioperative management of colorectal patients. ER and laparoscopy have a synergic effect to improve the postoperative recovery and reduce morbidity. Early discharge of patients does not affect the outcome of postoperative complications.