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Papanikolaou A, Chen SY, Radomski SN, Stem M, Brown LB, Obias VJ, Graham AE, Chung H. Short-Stay Left Colectomy for Colon Cancer: Is It Safe? J Am Coll Surg 2024; 238:172-181. [PMID: 37937826 DOI: 10.1097/xcs.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Advances in surgical practices have decreased hospital length of stay (LOS) after surgery. This study aimed to determine the safety of short-stay (≤24-hour) left colectomy for colon cancer patients in the US. STUDY DESIGN Adult colon cancer patients who underwent elective left colectomies were identified using the American College of Surgeons NSQIP database (2012 to 2021). Patients were categorized into 4 LOS groups: LOS 1 day or less (≤24-hour short stay), 2 to 4, 5 to 6, and 7 or more. Primary outcomes were 30-day postoperative overall and serious morbidity. Secondary outcomes were 30-day mortality and readmission. Multivariable logistic regression was performed to explore the association between LOS and overall and serious morbidity. RESULTS A total of 15,745 patients who underwent left colectomies for colon cancer were identified with 294 (1.87%) patients undergoing short stay. Short-stay patients were generally younger and healthier with lower 30-day overall morbidity rates (LOS ≤1 day: 3.74%, 2 to 4: 7.38%, 5 to 6: 16.12%, and ≥7: 37.64%, p < 0.001). Compared with patients with LOS 2 to 4 days, no differences in mortality and readmission rates were observed. On adjusted analysis, there was no statistical difference in the odds of overall (LOS 2 to 4 days: odds ratio 1.90, 95% CI 1.01 to 3.60, p = 0.049) and serious morbidity (LOS 2 to 4 days: odds ratio 0.86, 95% CI 1.42 to 1.76, p = 0.672) between the short-stay and LOS 2 to 4 days groups. CONCLUSIONS Although currently performed at low rates in the US, short-stay left colectomy is safe for a select group of patients. Attention to patient selection, refinement of clinical pathways, and close follow-up may enable short-stay colectomies to become a more feasible reality.
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Affiliation(s)
- Angelos Papanikolaou
- From the Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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McLemore EC, Lee L, Hedrick TL, Rashidi L, Askenasy EP, Popowich D, Sylla P. 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. Surg Endosc 2022; 36:7898-7914. [PMID: 36131162 PMCID: PMC9491699 DOI: 10.1007/s00464-022-09606-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/28/2022] [Indexed: 01/06/2023]
Abstract
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.
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Affiliation(s)
- Elisabeth C McLemore
- Bernard J. Tyson Kaiser Permanente School of Medicine, Los Angeles Medical Center, Los Angeles, CA, 90027, USA.
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Colon and Rectal Surgery, Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA, 90027, USA.
| | - Lawrence Lee
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health, Charlottesville, VA, USA
| | | | - Erik P Askenasy
- Division of Colon and Rectal Surgery, University of Texas Health, Houston, TX, USA
| | - Daniel Popowich
- Division of Colon and Rectal Surgery, St. Francis Hospital, New York, NY, USA
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Tavernier C, Flaris AN, Passot G, Glehen O, Kepenekian V, Cotte E. Assessing Criteria for a Safe Early Discharge After Laparoscopic Colorectal Surgery. JAMA Surg 2021; 157:52-58. [PMID: 34730770 DOI: 10.1001/jamasurg.2021.5551] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Early discharge after colorectal surgery has been advocated. However, there is little research evaluating clinical and/or laboratory criteria to determine who can be safely discharged early. Objective To evaluate the diagnostic performance of a C-reactive protein (CRP) level combined with 4 clinical criteria in ruling out an anastomotic leak and therefore allowing an early discharge on postoperative day 2 or 3. Design, Setting, and Participants This prospective, single-center cohort study was performed between February 2012 and July 2017. All consecutive adult patients undergoing laparoscopic colorectal surgery were included. All patients were followed up for 30 days postoperatively. Data analysis was performed in May 2021. Exposures Whether the 5 discharge criteria were fulfilled on postoperative day 3 (or day 2 for patients discharged on day 2). Fulfillment was defined as a CRP level less than 150 mg/dL on the day of discharge, a return of bowel function, tolerance of a diet, pain less than 5 of 10 on a visual analog scale, and being afebrile during the entire stay. Main Outcomes and Measures The primary outcome measurement was the diagnostic performance of the 5 discharge criteria in anticipating anastomotic leak development. The diagnostic performance of CRP level alone and 4 clinical criteria alone was also evaluated. Secondary measures were anastomotic leaks and mortality rates up to postoperative day 30. A discharge was successful if the patient left the hospital on postoperative day 2 or 3 without any complications or readmissions. Results A total of 287 patients were included (median [IQR] age, 58 [20] years; 141 men [49%] and 146 women [51%]). Mortality was 0%. There were 17 anastomotic leaks, of which 2 were on day 1 and were excluded. A total of 128 patients fulfilled all criteria, and 125 did not, including 34 for whom data were missing. Two leaks occurred in patients who had fulfilled all criteria vs 13 leaks in patients who did not (hazard ratio, 0.15 [95% CI, 0.03-0.69]; P = .01). Seventy-six of 128 patients (59.4%) were discharged successfully by postoperative day 3. The negative predictive value in ruling out an anastomotic leak was at least 96.9% for CRP alone (96.9% [95% CI, 93.3%-98.8%]), the 4 clinical criteria (98.4% [95% CI, 95.3%-99.7%]), and all 5 criteria combined (98.4% [95% CI, 94.5%-99.8%]). False-negative rates were 40% (95% CI, 16.3%-67.7%) for CRP level alone, 20% (95% CI, 4.3%-48.1%) for the other 4 criteria, and 13.3% (95% CI, 0%-40.5%) for all 5 criteria. Conclusions and Relevance These 5 criteria have a high negative predictive value and the lowest false-negative rate, indicating they have the potential to allow for safe early discharge after laparoscopic colorectal surgery.
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Affiliation(s)
- Clement Tavernier
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alexandros N Flaris
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.,Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Guillaume Passot
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.,EMR 37-38, Lyon 1 University, Lyon, France
| | - Olivier Glehen
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.,EMR 37-38, Lyon 1 University, Lyon, France
| | - Vahan Kepenekian
- Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.,EMR 37-38, Lyon 1 University, Lyon, France
| | - Eddy Cotte
- EMR 37-38, Lyon 1 University, Lyon, France.,Department of Digestive and Oncological Surgery, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France
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6
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Song BM, Kadhim M, Shanmugam JP, King AG, Heffernan MJ. Enhanced Recovery After Pediatric Scoliosis Surgery: Key Components and Current Practice. Orthopedics 2020; 43:e338-e344. [PMID: 32745223 DOI: 10.3928/01477447-20200721-06] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/09/2019] [Indexed: 02/03/2023]
Abstract
With the goal of safety and efficiency in health care delivery, enhanced recovery protocols (ERPs) continue to gain traction throughout various surgical disciplines, including in pediatric scoliosis surgery. The growing body of literature reporting decreased length of stay and cost with no change in readmissions or complications has brought these protocols to the forefront. The key components of ERPs include preoperative patient counseling, perioperative pain management, and early patient mobilization. In this review, the authors aim to describe the foundational history and major components of ERPs following pediatric spine deformity surgery. [Orthopedics. 2020;43(5):e338-e344.].
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Bednarski BK, Nickerson TP, You YN, Messick CA, Speer B, Gottumukkala V, Manandhar M, Weldon M, Dean EM, Qiao W, Wang X, Chang GJ. Randomized clinical trial of accelerated enhanced recovery after minimally invasive colorectal cancer surgery (RecoverMI trial). Br J Surg 2019; 106:1311-1318. [PMID: 31216065 DOI: 10.1002/bjs.11223] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) and enhanced recovery protocols (ERPs) have improved postoperative recovery and shortened length of hospital stay (LOS). Telemedicine technology has potential to improve outcomes and patient experience further. This study was designed to determine whether the combination of MIS, ERP and a structured telemedicine programme (TeleRecovery) could shorten total 30-day LOS by 50 per cent. METHODS This was a phase II prospective RCT at a large academic medical centre. Eligible patients aged 18-80 years undergoing minimally invasive colorectal resection using an ERP were randomized after surgery. The experimental arm (RecoverMI) included accelerated discharge on postoperative day (POD) 1 with or without evidence of bowel function and a televideoconference on POD 2. The control arm was standard postoperative care. The primary endpoint was total 30-day LOS (postoperative stay plus readmission/emergency department/observation days). Secondary endpoints included patient-reported outcomes measured by EQ-5D-5L™, Brief Pain Inventory (BPI) and a satisfaction questionnaire. RESULTS Thirty patients were randomized after robotic (21 patients) or laparoscopic (9) colectomy, including 14 patients in the RecoverMI arm. Median 30-day total LOS was 28·3 (i.q.r. 23·7-43·6) h in the RecoverMI arm and 51·5 (43·8-67·0) h in the control arm (P = 0·041). There were no differences in severe adverse events or EQ-5D-5L™ score between the study arms. The BPI revealed low pain scores regardless of treatment arm. Satisfaction was high in both arms. CONCLUSION In patients having surgery for colorectal neoplasms, the trimodal combination of MIS, ERP and TeleRecovery can reduce 30-day LOS while preserving patients' quality of life and satisfaction. Registration number: NCT02613728 ( https://clinicaltrials.gov).
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Affiliation(s)
- B K Bednarski
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - T P Nickerson
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Y N You
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C A Messick
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - B Speer
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - V Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M Manandhar
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M Weldon
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - E M Dean
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - W Qiao
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - X Wang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G J Chang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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8
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Implementation of day of surgery admission for rectal cancer surgery in Ireland following a national centralisation programme. Ir J Med Sci 2018; 188:765-769. [DOI: 10.1007/s11845-018-1904-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 09/19/2018] [Indexed: 01/12/2023]
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Emmanuel A, Chohda E, Botfield C, Ellul J. Accelerated discharge within 72 hours of colorectal cancer resection using simple discharge criteria. Ann R Coll Surg Engl 2017; 100:52-56. [PMID: 29022790 DOI: 10.1308/rcsann.2017.0149] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Introduction Short hospital stays and accelerated discharge within 72 hours following colorectal cancer resections have not been widely achieved. Series reporting on accelerated discharge involve heterogeneous patient populations and exclude important groups. Strict adherence to some discharge requirements may lead to delays in discharge. The aim of this study was to evaluate the safety and feasibility of accelerated discharge within 72 hours of all elective colorectal cancer resections using simple discharge criteria. Methods Elective colorectal cancer resections performed between August 2009 and December 2015 by a single surgeon were reviewed. Perioperative care was based on an enhanced recovery programme. A set of simplified discharge criteria were used. Outcomes including postoperative complications, readmissions and reoperations were compared between patients discharged within 72 hours and those with a longer postoperative stay. Results Overall, 256 colorectal cancer resections (90% laparoscopic) were performed. The mean patient age was 70.8 years. The median length of stay was 3 days. Fifty-eight per cent of all patients and sixty-three per cent of patients undergoing laparoscopic surgery were discharged within 72 hours. Accelerated discharge was not associated with adverse outcomes compared with delayed discharge. Patients discharged within 72 hours had significantly fewer postoperative complications, readmissions and reoperations. Open surgery and stoma formation were associated with discharge after 72 hours but not age, co-morbidities, neoadjuvant chemoradiation or surgical procedure. Conclusions Accelerated discharge within 72 hours of elective colorectal resection for cancer is safely achievable for the majority of patients without compromising short-term outcomes.
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Affiliation(s)
- A Emmanuel
- King's College Hospital NHS Foundation Trust , UK
| | - E Chohda
- King's College Hospital NHS Foundation Trust , UK
| | - C Botfield
- King's College Hospital NHS Foundation Trust , UK
| | - J Ellul
- King's College Hospital NHS Foundation Trust , UK
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Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Steele SR, Feldman LS. Clinical practice guideline for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 2017; 31:3412-3436. [DOI: 10.1007/s00464-017-5722-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022]
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Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017; 60:761-784. [PMID: 28682962 DOI: 10.1097/dcr.0000000000000883] [Citation(s) in RCA: 258] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Price BA, Bednarski BK, You YN, Manandhar M, Dean EM, Alawadi ZM, Bryce Speer B, Gottumukkala V, Weldon M, Massey RL, Wang X, Qiao W, Chang GJ. Accelerated enhanced Recovery following Minimally Invasive colorectal cancer surgery ( RecoverMI): a study protocol for a novel randomised controlled trial. BMJ Open 2017; 7:e015960. [PMID: 28729319 PMCID: PMC5642654 DOI: 10.1136/bmjopen-2017-015960] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Definitive treatment of localised colorectal cancer involves surgical resection of the primary tumour. Short-stay colectomies (eg, 23-hours) would have important implications for optimising the efficiency of inpatient care with reduced resource utilisation while improving the overall recovery experience with earlier return to normalcy. It could permit surgical treatment of colorectal cancer in a wider variety of settings, including hospital-based ambulatory surgery environments. While a few studies have shown that discharge within the first 24 hours after minimally invasive colectomy is possible, the safety, feasibility and patient acceptability of a protocol for short-stay colectomy for colorectal cancer have not previously been evaluated in a prospective randomised study. Moreover, given the potential for some patients to experience a delay in recovery of bowel function after colectomy, close outpatient monitoring may be necessary to ensure safe implementation. METHODS AND ANALYSIS In order to address this gap, we propose a prospective randomised trial of accelerated enhanced Recovery following Minimally Invasive colorectal cancer surgery (RecoverMI) that leverages the combination of minimally invasive surgery with enhanced recovery protocols and early coordinated outpatient remote televideo conferencing technology (TeleRecovery) to improve postoperative patien-provider communication, enhance postoperative treatment navigation and optimise postdischarge care. We hypothesise that RecoverMI can be safely incorporated into multidisciplinary practice to improve patient outcomes and reduce the overall 30-day duration of hospitalisation while preserving the quality of the patient experience. ETHICS AND DISSEMINATION: RecoverMI has received institutional review board approval and funding from the American Society of Colorectal Surgeons (ASCRS; LPG103). Results from RecoverMI will be published in a peer-reviewed publication and be used to inform a multisite trial. TRIAL REGISTRATION NUMBER NCT02613728; Pre-results.
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Affiliation(s)
- Brandee A Price
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brian K Bednarski
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Y Nancy You
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Clinical Cancer Genetics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Meryna Manandhar
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - E Michelle Dean
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeinab M Alawadi
- UTHealth Center for Clinical and Translational Sciences, Houston, Texas, USA
- University of Texas Health Science Center, Houston, Texas, USA
| | - B Bryce Speer
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marla Weldon
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Robert L Massey
- Department of Nursing, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xuemei Wang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wei Qiao
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - George J Chang
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Health Services Research, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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13
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Kunisawa S, Fushimi K, Imanaka Y. Reducing Length of Hospital Stay Does Not Increase Readmission Rates in Early-Stage Gastric, Colon, and Lung Cancer Surgical Cases in Japanese Acute Care Hospitals. PLoS One 2016; 11:e0166269. [PMID: 27832182 PMCID: PMC5104332 DOI: 10.1371/journal.pone.0166269] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 10/25/2016] [Indexed: 01/12/2023] Open
Abstract
Background The Japanese government has worked to reduce the length of hospital stay by introducing a per-diem hospital payment system that financially incentivizes the timely discharge of patients. However, there are concerns that excessively reducing length of stay may reduce healthcare quality, such as increasing readmission rates. The objective of this study was to investigate the temporal changes in length of stay and readmission rates as quality indicators in Japanese acute care hospitals. Methods We used an administrative claims database under the Diagnosis Procedure Combination Per-Diem Payment System for Japanese hospitals. Using this database, we selected hospitals that provided data continuously from July 2010 to March 2014 to enable analyses of temporal changes in length of stay and readmission rates. We selected stage I (T1N0M0) gastric, colon, and lung cancer surgical patients who had been discharged alive from the index hospitalization. The outcome measures were length of stay during the index hospitalization and unplanned emergency readmissions within 30 days after discharge. Results From among 804 hospitals, we analyzed 42,585, 15,467, and 40,156 surgical patients for gastric, colon, and lung cancer, respectively. Length of stay was reduced by approximately 0.5 days per year. In contrast, readmission rates were generally stable at approximately 2% or had decreased slightly over the 4-year period. Conclusions In early-stage gastric, colon, and lung cancer surgical patients in Japan, reductions in length of stay did not result in increased readmission rates.
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Affiliation(s)
- Susumu Kunisawa
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuichi Imanaka
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- * E-mail:
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Chand M, De’Ath HD, Rasheed S, Mehta C, Bromilow J, Qureshi T. The influence of peri-operative factors for accelerated discharge following laparoscopic colorectal surgery when combined with an enhanced recovery after surgery (ERAS) pathway. Int J Surg 2016; 25:59-63. [DOI: 10.1016/j.ijsu.2015.11.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 11/07/2015] [Accepted: 11/22/2015] [Indexed: 12/20/2022]
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15
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Is expedited early discharge following elective surgery for colorectal cancer safe? An analysis of short-term outcomes. Surg Endosc 2015; 30:3904-9. [DOI: 10.1007/s00464-015-4696-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
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16
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Gash K, Bicsak M, Dixon A. Single-incision laparoscopic surgery for rectal cancer: early results and medium-term oncological outcome. Colorectal Dis 2015; 17:1071-8. [PMID: 26076762 DOI: 10.1111/codi.13034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 03/27/2015] [Indexed: 12/20/2022]
Abstract
AIM Conventional laparoscopic surgery for rectal cancer management is now widely accepted as an alternative to open surgery, bestowing specific advantages without causing detriment to oncological outcome. Evolving from this, single-incision laparoscopic surgery (SILS) has been successfully utilized for the removal of colonic tumours, but the literature lacks data analysing the suitability of SILS for rectal cancer resection, particularly on oncological outcome. We report the medium-term oncological outcome from a prospective observational study of SILS for rectal cancer, including high and low anterior resections. METHOD A prospective electronic database was collated of all patients undergoing SILS rectal cancer resection in our institution, between 2009 and 2014. In addition to patient, tumour and operative data, histopathological and medium-term oncological end-points were recorded. Kaplan-Meier curves were used to analyse survival. RESULTS Sixty-one patients underwent SILS for rectal cancer by high anterior resection (n = 34), low anterior resection with total mesorectal excision (TME) (n = 24) and low anterior resection with TME and hand-sewn colo-anal anastomosis (n = 3). The median operation time was 105 (37-280) min and 92% of cases were completed by SILS. The mean interval to resuming oral feeding was 11 h and the median length of stay was 2 (1-8) days. The median number of lymph nodes found by the histopathologist in the resected specimen was 18 (6-44) and all operations completely removed the tumour (R0 resection). At a median follow-up of 46 (16-64) months, eight (13%) patients developed metastatic disease, of whom three had local recurrence. Overall, three patients have died, of whom all had metastatic disease. CONCLUSION Anterior resection with TME for rectal cancer can be safely performed using the SILS technique, with acceptable histopathological results and good oncological outcome.
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Affiliation(s)
- K Gash
- Department of Colorectal Surgery, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, UK
| | | | - A Dixon
- Department of Colorectal Surgery, North Bristol NHS Trust, Southmead Hospital, Westbury-on-Trym, Bristol, UK.,SPIRE* Hospital, Bristol, UK
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Johnson BL, Davis BR, Rafferty JF, Paquette IM. Postoperative predictors of early discharge following laparoscopic segmental colectomy. Int J Colorectal Dis 2015; 30:703-6. [PMID: 25680546 DOI: 10.1007/s00384-015-2153-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE There is increasing pressure to shorten length of stay (LOS) after major surgical procedures. Although laparoscopic colectomy has been shown to have shorter LOS than open colectomy, not all patients experience a short length of stay. Predictive factors for early discharge after laparoscopic colectomy have not been clearly defined. We hypothesized that patients who exhibit a brisk urine output and lack of a systemic inflammatory response on the first postoperative day would experience a shorter postoperative stay after laparoscopic colectomy. METHODS We performed a retrospective review of patients undergoing laparoscopic segmental colectomy by one of colorectal surgeons from 2012 to 2013. Patient demographics, operative characteristics, and postoperative factors were examined. A multiple linear regression model was used to examine the impact of various factors on length of stay, while controlling for confounding variables. Systemic inflammatory response syndrome (SIRS) was defined using Society of Critical Care Medicine consensus definitions. RESULTS A total of 127 patients underwent a laparoscopic segmental colectomy. When controlling for confounding variables, ileus, postoperative complication, and SIRS response were associated with 2.67, 1.16, and 0.42 additional hospital days, respectively, while each additional liter of urine output on postoperative day 1 was associated with a 0.23-day decrease in LOS (p = 0.006). CONCLUSIONS In the absence of postoperative ileus or overt complication, patients who do not exhibit a SIRS response, and have a brisk urine output on postoperative day (POD) 1, may be targeted for early hospital discharge after laparoscopic colectomy.
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Affiliation(s)
- Bobby L Johnson
- Division of Colon and Rectal Surgery, Department of Surgery, University of Cincinnati College of Medicine, 2123 Auburn Avenue Suite 524, Cincinnati, OH, 45219, USA
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18
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General and vascular surgery readmissions: a systematic review. J Am Coll Surg 2014; 219:552-69.e2. [PMID: 25067801 DOI: 10.1016/j.jamcollsurg.2014.05.007] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/08/2014] [Accepted: 05/14/2014] [Indexed: 01/08/2023]
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19
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Hammond J, Lim S, Wan Y, Gao X, Patkar A. The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes. J Gastrointest Surg 2014; 18:1176-85. [PMID: 24671472 PMCID: PMC4028541 DOI: 10.1007/s11605-014-2506-4] [Citation(s) in RCA: 148] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the clinical and economic burden associated with anastomotic leaks following colorectal surgery. METHODS Retrospective data (January 2008 to December 2010) were analyzed from patients who had colorectal surgery with and without postoperative leaks, using the Premier Perspective™ database. Data on in-hospital mortality, length of stay (LOS), re-admissions, postoperative infection, and costs were analyzed using univariate and multivariate analyses, and the propensity score matching (PSM) and generalized linear models (GLM). RESULTS Of the patients, 6,174 (6.18 %) had anastomotic leaks within 30 days after colorectal surgery. Patients with leaks had 1.3 times higher 30-day re-admission rates and 0.8-1.9 times higher postoperative infection rates as compared with patients without leaks (P < 0.001 for both). Anastomotic leaks incurred additional LOS and hospital costs of 7.3 days and $24,129, respectively, only within the first hospitalization. Per 1,000 patients undergoing colorectal surgery, the economic burden associated with anastomotic leaks--including hospitalization and re-admission--was established as 9,500 days in prolonged LOS and $28.6 million in additional costs. Similar results were obtained from both the PSM and GLM for assessing total costs for hospitalization and re-admission. CONCLUSIONS Anastomotic leaks in colorectal surgery increase the total clinical and economic burden by a factor of 0.6-1.9 for a 30-day re-admission, postoperative infection, LOS, and hospital costs.
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Affiliation(s)
| | - Sangtaeck Lim
- Global Health Economics and Market Access, Ethicon, Inc, Somerville, NJ 08876 USA
| | - Yin Wan
- Health Outcomes Research, Pharmerit North America LLC, Bethesda, MD 20814 USA
| | - Xin Gao
- Health Outcomes Research, Pharmerit North America LLC, Bethesda, MD 20814 USA
| | - Anuprita Patkar
- Global Health Economics and Market Access, Ethicon, Inc, Somerville, NJ 08876 USA
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Couch DG, Luther A, Farid S, Kang P. Response to Gash et al.: Enhanced recovery after laparoscopic colorectal resection with primary anastomosis: accelerated discharge is safe and does not give rise to increased readmission rates. Colorectal Dis 2013; 15:758. [PMID: 23701322 DOI: 10.1111/codi.12184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Affiliation(s)
- D. G. Couch
- Northampton General Hospital NHS Trust; Cliftonville Road; Northampton; NN1 5BD; UK
| | - A. Luther
- Northampton General Hospital NHS Trust; Cliftonville Road; Northampton; NN1 5BD; UK
| | - S. Farid
- Northampton General Hospital NHS Trust; Cliftonville Road; Northampton; NN1 5BD; UK
| | - P. Kang
- Northampton General Hospital NHS Trust; Cliftonville Road; Northampton; NN1 5BD; UK
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Gash K, Greenslade G, Dixon A. Reply to Couch et al. Colorectal Dis 2013; 15:759. [PMID: 23560641 DOI: 10.1111/codi.12234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 03/14/2013] [Indexed: 02/08/2023]
Affiliation(s)
- K. Gash
- North Bristol NHS Trust; Frenchay Hospital; Department of Surgery; Beckspool Road; Bristol BS16 1JE; UK
| | - G. Greenslade
- North Bristol NHS Trust; Frenchay Hospital; Department of Surgery; Beckspool Road; Bristol BS16 1JE; UK
| | - A. Dixon
- North Bristol NHS Trust; Frenchay Hospital; Department of Surgery; Beckspool Road; Bristol BS16 1JE; UK
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Slim A, Garancini M, Di Sandro S, Mangoni I, Lauterio A, Giacomoni A, De Carlis L. Laparoscopic versus open liver surgery: a single center analysis of post-operative in-hospital and post-discharge results. Langenbecks Arch Surg 2012; 397:1305-11. [PMID: 22918605 DOI: 10.1007/s00423-012-0992-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 08/02/2012] [Indexed: 12/23/2022]
Abstract
PURPOSE Laparoscopic hepatectomy (LH) is established as a safe and feasible surgical procedure for benign and malignant liver lesions showing many benefits in terms of short-term post-operative outcomes. Nevertheless, it remains unclear if these benefits extend beyond the hospital stay. The aim of this study was to compare in-hospital and post-discharge outcomes between two groups of patients who have undergone either laparoscopic or open hepatectomy (OH). METHODS Forty-six patients who have undergone LH from September 2008 to September 2011 were compared to 46 matched-pair control patients who have undergone OH. The two groups were compared in terms of in-hospital and 6-month outcomes. Post-discharge outcomes were analyzed in terms of the number of outpatient clinic appointments (OCAs) and readmissions (RAs). Analyses were performed excluding and including conversion cases. RESULTS The two groups resulted in homogeneous patients' and lesions' characteristics. Patients who underwent LH showed statistically lower intra-operative blood loss, less total and major morbidity and shorter hospital stay. Regarding post-discharge outcomes, significantly less patients of LH group compared to patients of OH group required more than two post-discharge OCAs (in the intention to treat analysis, 28.3 versus 63%, respectively; P = 0.006) or RA (4.3 versus 15.2%, respectively; P = 0.008). The benefits of LH appeared to be maximized in cirrhotic patients; those represented the large part of patients readmitted after hepatectomy regardless of the type of surgical approach (77.8%). CONCLUSIONS Advantages related to LH extend over the post-discharge period suggesting potential better patient's satisfaction and lower hospital cost.
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Affiliation(s)
- Abdallah Slim
- Liver-Pancreas-Kidney Transplantation Surgical Unit, Department of General, HPB Surgery and Transplantation, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore, 3, Milan, Italy.
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