Intrinsic predictors of prolonged length of stay in a colorectal enhanced recovery pathway: a prospective cohort study and multivariate analysis

Assessing the environmental impact of an anastomotic leak care pathway

Background

The healthcare sector faces increasing pressure to improve environmental sustainability whilst continuing to meet the needs of patients. One strategy is to lower the avoidable demand on healthcare services, by reducing the number of surgical complications, such as anastomotic leak (AL). The aim of this study was to assess the environmental impact associated with the care pathway of AL.

Methods

An environmental impact assessment was performed according to the Sustainable Healthcare Coalition (SHC) guidelines. A care pathway, describing the typical steps involved in the diagnosis and treatment of AL was developed. Activity and emission data for each stage of the care pathway were used to calculate the climate, water and waste impact of the treatment of AL patients.

Results

The environmental impact assessment shows that AL is associated with an average climate, water and waste impact per patient of 1303 kg CO₂-eq, 1803 m³ of water and 123 kg waste, respectively. Grade C leaks are associated with the greatest environmental impact, contributing to 89.3 %, 79.4 % and 97.9 % of each impact, respectively. A breakdown of the environmental impact of each activity shows that stoma home management is the largest contributor to the total climate (46.6 %) and waste (47.3 %) impact of AL patients, whilst in-patient hospital stay contributes greatest to the total water impact (46.7 %).

Conclusions

The treatment of AL is associated with a substantial environmental impact. This study is, to our knowledge, the first to assess the environmental impact associated with the treatment of AL.

Effect of Anterograde Lavage via Temporary Loop Ileostoma on the Recovery of Bowel Function in Patients Receiving Stoma Closure: A Retrospective Cohort Study

BACKGROUND

The effect of anterograde lavage in patients with rectal cancer who underwent anterior resection and plan to receive stoma closure is unclear.

OBJECTIVE

This study aimed to investigate the effect of anterograde lavage on postoperative bowel function recovery in patients who underwent temporary loop ileostomy and stoma closure.

DESIGN

This was a hospital-based retrospective cohort study.

SETTINGS

This study was conducted at a tertiary referral center.

PATIENTS

All consecutive patients who underwent anterior resection for rectal cancer and were planning to receive stoma closure from March through December 2019 were included.

INTERVENTIONS

The enrolled patients were divided into 2 groups according to whether they received anterograde lavage before stoma closure.

MAIN OUTCOME MEASURES

Short-term functional outcomes, including time to first passing of flatus, first defecation time, and recovery time to first meal, were compared between the groups. Secondary outcomes included length of hospital stay, total cost of hospitalization, and postoperative complications.

RESULTS

A total of 222 eligible participants were included in the analysis, including 114 in the lavage group and 108 in the nonlavage group. No statistically significant differences were found in age, sex ratio, or distance between the anastomotic line and dentate line. In the lavage group, patients' time to first passing of flatus (38 vs 42 h; p = 0.006), first defecation time (42 vs 48 h; p < 0.001), recovery time to first meal (48 vs 55.5 h; p < 0.001), and length of hospital stay (5 vs 7 d; p < 0.001) were significantly shorter than those in the nonlavage group, and the total cost of hospitalization was significantly lower than that of the nonlavage group (25,000 vs 28,000 RMB; p < 0.001). No significant difference was found in the incidence of postoperative complications between the 2 groups (p = 0.067).

LIMITATIONS

This study is limited by its relatively small sample size and retrospective design with single-center participants.

CONCLUSIONS

Anterograde lavage before stoma closure is safe and noninvasive. For patients receiving anterior resection and planning to have stoma closure, this procedure can potentially help recover bowel function more rapidly. See Video Abstract at http://links.lww.com/DCR/C51.

EFECTO DEL LAVADO ANTERGRADO MEDIANTE ILEOSTOMA TEMPORAL EN ASA SOBRE LA RECUPERACIN DE LA FUNCIN INTESTINAL EN PACIENTES QUE RECIBEN CIERRE DE ESTOMA UN ESTUDIO DE COHORTE RETROSPECTIVO

ANTECEDENTES:No está claro el efecto del lavado anterógrado en pacientes con cáncer de recto con resección anterior que planean recibir el cierre del estoma.OBJETIVO:Investigar el efecto del lavado anterógrado en la recuperación de la función intestinal posoperatoria en pacientes que se sometieron a ileostomía en asa temporal y cierre de estoma.DISEÑO:Estudio de cohorte retrospectivo basado en el hospital.AJUSTES:Centro de referencia terciario.PACIENTES:Todos los pacientes que se sometieron a una resección anterior por cáncer de recto y que planeaban recibir el cierre del estoma desde marzo hasta diciembre de 2019.INTERVENCIONES:Los pacientes inscritos se dividieron en dos grupos según si recibieron lavado anterógrado antes del cierre del estoma.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados funcionales a corto plazo, incluido el tiempo de la primera evacuación de flatos, tiempo de la primera defecación y tiempo de recuperación hasta la primera comida, se compararon entre los grupos. Resultados secundarios incluyeron duración de la estancia hospitalaria, costo total de la hospitalización y complicaciones posoperatorias.RESULTADOS:Se incluyeron en el análisis un total de 222 participantes elegibles, incluidos 114 en el grupo de lavado y 108 en el grupo de no lavado. No hubo diferencias estadísticamente significativas en la edad, la proporción de sexos o la distancia entre la línea de anastomosis y la línea dentada. En el grupo de lavado, el tiempo de la primera evacuación de flatos de los pacientes (38 vs 42 h; p = 0,006), el tiempo de la primera defecación (42 vs 48 h; p < 0,001), el tiempo de recuperación hasta la primera comida (48 vs 55,5 h; p < 0,001) y la duración de la estancia hospitalaria (5 vs 7 días; p < 0,001) fueron significativamente más cortos que los del grupo de no lavado, y el costo total de la hospitalización fue significativamente menor que el del grupo de no lavado (25000 vs 28000 RMB; p < 0,001). No hubo diferencia significativa en la incidencia de complicaciones postoperatorias entre los dos grupos (p = 0,067).LIMITACIONES:Este estudio está limitado por su tamaño de muestra relativamente pequeño y su diseño retrospectivo con participantes de un solo centro.CONCLUSIONES:El lavado anterógrado antes del cierre del estoma es seguro y no invasivo. Para los pacientes que se someten a una resección anterior y planean cerrar el estoma, este procedimiento puede ayudar potencialmente a recuperar la función intestinal más rápidamente. Consulte Video Resumen en http://links.lww.com/DCR/C51. (Traducción-Dr. Francisco M. Abarca-Rendon).

Ileostomy Patients Using Patient Engagement Technology Experience Decreased Length of Stay

Patients who undergo colorectal surgery, particularly, construction of a new ileostomy, are known to have longer length of stay (LOS) and increased readmissions. With the increased availability of patient engagement technology (PET), we hypothesized that because PET facilitates education before and after surgery, ileostomy patients who used PET would have decreased LOS without increasing readmissions. Variables were obtained from the National Surgical Quality Improvement Program (NSQIP) database for patients undergoing ileostomy construction. Study patients were categorized into three groups: pre-PET (patients prior to PET), non-PET (patients who did not use PET), and PET users (patients who used PET). Univariate analysis of patient and surgical characteristics, LOS, ED visits, and readmissions and multivariable modeling of potential predictors of LOS were performed. There were 106 patients in the pre-PET, 51 in the PET, and 108 in the non-PET and cohorts were similar except pre-op diagnosis. Length of stay was lower for the PET cohort (p = 0.0001), with no significant difference in readmission or ED visits. On multivariable analysis, we identified the PET cohort as an independent predictor of shorter LOS relative to non-PET and pre-PET (p = 0.007 and p = 0.02, respectively). Similarly, patients had significantly shorter LOS who had a diagnosis of neoplasm as compared to IBD (p = 0.03). Hypertension requiring medication (p = 0.001) and Black race relative to White race (p = 0.002) were independent predictors of longer LOS. In this study of ileostomy patients, we have shown that use of PET is an independent predictor of decreased LOS without increased ED visits or readmissions.