ERA(S) laparoscopic colorectal resection is safe & does not lead to an increased readmission rate
Enhanced Recovery after laparoscopic colorectal
resection with primary anastomosis; accelerated discharge is safe and does not
give rise to increased readmission rates.
GL Greenslade, AR Dixon
Hospital, North Bristol NHS Trust, UK, BS16 1L
Aims: Enhanced recovery programmes (ERP)
after colorectal surgery are promoted to minimise complications and expedite
recovery, thus reducing length of hospital stay where appropriate and improving the overall standard of
patient care. There are few
published trials of ERPs in the context of laparoscopic colorectal
Methods: Data was prospectively collected on all
laparoscopic colorectal resections carried out in our institution from May 2004
to November 2009. An informal move
to 48 hour discharge was introduced in May 2004 and the official ERP launched in
November 2008. We identified all
patients with a primary anastomosis discharged within 3 days of surgery. Early outcomes: leaks, complications,
readmission rates and returns to theatre were analysed.
Results: 606 resections were performed in this
period. Median length of stay was four
days (0-52). 279 patients met the
criteria of accelerated discharge by day 3 (46%). Of these, two (0.7%) were discharged on the day of surgery,
25.1% (70) within 24 hours, 41.6% (116) within 48 hours and 32.6% (91) by 72
hours. Age was not a significant
factor in determining length of stay.
Patients undergoing right hemicolectomy were more likely to be
discharged by 24 hours than those with left-sided anastomoses and patients
having TME resections were more likely to stay 3 days. The readmission rate was 4%, regardless
of day of discharge.
Conclusion: Accelerated discharge is feasible and
safe. High readmission rates reported in ERPs after open colorectal surgery
have not occurred in our laparoscopic experience.
What is new in this paper?
undergoing laparoscopic colorectal surgery within an enhanced recovery
programme did not experience high readmission rates reported in the literature
for open surgery; only 4% despite discharge at 24 hours. 50% of patients
discharged within 72 hours were over 70 years; highlighting the value of ERPs
in all laparoscopic colorectal patients.
programmes (ERP) following colorectal surgery have been introduced in NHS
hospitals across the UK, supported by a Department of Health ‘partnership programme’ .
The benefits to patients and healthcare systems are backed-up by a
multitude of evidence-based studies and more importantly, reports from UK
hospitals following its introduction.
The majority of the evidence is based on open colorectal surgery. The main drawback reported with ERP has
been hospital readmission; initial Danish studies reported a readmission rate
of 15% when patients were discharged home at median of 2 days . Recent
studies report more acceptable readmission rates of 8% following open surgery
(median stay 6 days)  and 6% in laparoscopic surgery (median stay 5 days) . Many surgeons believe that laparoscopic
surgery confers no additional benefit to patients over open colorectal surgery
where an ERP is in place, and that the limiting factor is an increased
readmission rate if patients are discharged ‘too early’. This was demonstrated
by Basse et al who found no significant difference in length of stay between
open and laparoscopic groups (median 2 days for each), where all patients are
managed in accordance with ERP .
However, this minimal length of stay resulted in readmission rates of
27% (open) and 20% (laparoscopic). Such studies have lead to the suggestion
that there is a ceiling of benefit from ERP in terms of length of stay, with earlier
discharge having and adverse effect on readmission rates.
historical and current challenge in introducing the ERP in practice is the
psychological belief by patients, nurses and surgeons alike that early
discharge is disadvantageous to good and complete recovery; that early
discharge increases complications and thus readmissions. Challenging this belief is central in
launching a successful ERP. One
must remember that the goal of an ERP is not merely to discharge patients
earlier, but to accelerate patients’
recovery such that they are able to
be discharged; this may therefore be at an earlier point in time. The aim of
this study was to evaluate complication and readmission rates for patients in
an ERP who were discharged home “early” following aparoscopic colorectal
resection with primary anastomoses,
patients from a prospective, password protected, institutionally approved,
electronic database of all laparoscopic colorectal resections performed in our hospital from May 2004
to November 2009. We informally introduced
many of the ERP principles to our practice back in 2004, well before officially
launching an ERP in November 2008, in conjunction with an already established
laparoscopic colorectal surgery programme.
Fundamental to the
success of the ERP is individual patient understanding. Therefore, prior to admission all
patients are introduced to the concept that early postoperative mobilisation
and dietary intake is beneficial to recovery and may reduce postoperative
morbidity . . Preoperatively, patients are given a
400ml carbohydrate drink to consume on the morning of the procedure and they
are allowed to drink water until one hour prior to anaesthesia. We do not
routinely use oral bowel preparation, merely Phosphate enemas as appropriate.
techniques of note include the administration of pre-incision TAP (Transversus
Abdominus plane) and rectus sheath blocks, limited intra-operative opioids, three-port
laparoscopic resection or single incision laparoscopic surgery (SILS) where
possible, midline per-umbilical specimen extraction and importantly, limited theatre
and operative time. Epidurals and
patient controlled analgesia (PCAs) are not routinely used; physically they
hinder patients’ mobility and opioids impede bowel function causing ileus and
provoke nausea, resulting in a reluctance to eat [7, 8]. Sensation to the
anterior abdominal wall is supplied by the anterior rami of T7 –L1 and the
terminal branches of these somatic nerves pass through the plane between
Internal Oblique and Transversus Abdominus (the Transversus Abdominus Plane).
TAP blocks are performed under ultrasound guidance, with 20mls 0.375%
Bupivacaine injected into each side. This is our mainstay of analgesia .
allowed to eat and drink as soon as they arrive in the recovery bay or on the
ward. Urinary catheters are removed in theatre and mobilisation on the day of surgery is strongly
encouraged. If supplementary
analgesia is required, intravenous paracetamol and oral non-steroidal
anti-inflammatory drugs are first-line. Only if absolutely necessary is oral morphine
prescribed. Clinical judgement is used to assess
patients on a regular basis. It is
our view that patients who have undergone a successful, uncomplicated
laparoscopic colorectal resection, who do not suffer from any major prior co-morbidity
that could limit their recovery, should be well, mobile and tolerating diet on
first postoperative morning. A
high index of suspicion of complication exists for patients who do not appear
to be progressing. Hence patients
who recover promptly are discharged home “early”. Our criteria for discharge includes: pain
controlled with oral analgesia; absence of nausea and vomiting; ability to
mobilise; passage of flatus; ability to tolerate solid food and patient happy
to be discharge.
With the introduction of an official ERP in our
hospital we now also provide a telephone follow-up service for the first week after
discharge; this allows patients to go home confident that they will receive
prompt attention if complications do occur, and conversely ensures that we
receive feedback regarding early complications, including minor ones such as
wound infections which do not need readmission. Patients have a fast-track readmission route should this be
laparoscopic colorectal resections were performed between May 2004 and November
2009. Length of stay ranged
between 0 and 52 days (median 4 days).
279 patients met the criteria of “accelerated discharge” by day 3 (46%). Two (0.7%) were discharged on the day
of surgery (right hemicolectomy, colectomy and ileorectal anastomosis), 25.1%
(70) by 24 hours, 41.6% (116) by 48 hours and 32.6% (91) by 72 hours (Table 1). Procedures performed in this “accelerated discharge cohort”
were right hemicolectomy (74), extended right hemicolectomy (23), subtotal
colectomy and ileorectal anasomosis (6), anterior resection (134), total
mesorectal excision (TME) (36) and reversal of Hartmann’s (6).
not a significant factor in determining length of stay (Table 1). Within this
“early discharge” cohort (279
patients), of those discharged by 24 hours, only 54% were aged less than 70
years (range 23-92 years). Similarly, only 47% of those discharged on day 2 and
49% of patients who went home on day 3, were aged <70 years. Therefore, 140
patients over the age of 70 years were discharged within 3 days of colorectal
association between the specific procedure the patient underwent and day of
discharge was identified. Patients undergoing right hemicolectomy were more
likely to be discharged by 24 hours (41%) than those with left-sided anastomoses
(20%), (Table 2). Equally, those patients undergoing TME
resections were more likely to stay 3 days (50%) than anterior resections (32%)
or right hemicolectomies (24%).
overall readmission rate following all 606 resections, regardless of day of discharge,
was 4%. “Early” discharge had no impact on this. Readmission was required in 3
patients (4%) who had been discharged at 24 hours, 5 patients (4%) discharged
by 48 hours and 4 (4%) who went home by 72 hours, (Table 3). Reasons for readmission were: anastomotic leak (2), faint
(1), abscess (2), ischaemic colo-pouch (1), pancreatitis (1), wound infection
(1), small bowel obstruction (1), urinary tract infection (1) and ileus (2). Patients requiring return to theatre
included 2 (3%) who were discharged by 24 hours (anastomotic leak day 30 and
abscess day 11), 3 (2.6%) discharged by 48 hours (anastomotic leak and an
abscess) and 1 (1%) discharged on day 3 (ischaemic pouch). Each of these 6
patients successfully underwent reoperation and was discharged. There was no
90-day postoperative mortality.
We have found that
almost half of all patients undergoing laparoscopic colorectal resection with a
primary anastomosis, who were managed with enhanced recovery principles, had
recovered sufficiently to enable discharge by 72 hours. Moreover, 96% of these were discharged
successfully, without complication or readmission. This is in contrast to similar studies of open colorectal surgery within
an ERP, where readmission rates of 20% have been recorded, . However, we
appreciate that one must be judicious when comparing such readmission figures,
as they are not representative of our centre’s data for open colorectal surgery
and may be confounded by many factors. However, other studies have shown
that laparoscopic colorectal surgery has better short-term outcomes than open
surgery, when all patients are managed according to ERP principles . Providing good clinical judgement prevails and each patient is regarded
individually, a significant number of laparoscopic patients benefit from the
principles of the enhanced recovery protocols. Not applying these principles in laparoscopic colorectal
surgery may negate major benefits that laparoscopic surgery confers over open
In a recent multi-centre randomised trial,
laparoscopic colorectal resection with “fast track” (ERP) peri-operative care
was found to be the optimum form of management in terms of reducing length of
hospital stay and morbidity, when compared to open surgery with ERP or laparoscopy
with standard peri-operative care .
can still occur in those patients who are discharged home early; these can often
be dealt with in the community or may require readmission. However, in our
experience patients who are tolerating diet, mobilising independently,
experiencing minimal pain which is controlled by oral analgesia and who are
keen to go home promptly after surgery,
have “selected themselves” to have a lower risk of complications. Similarly, the type of colorectal
resection performed should not be a factor in determining length of stay. If a
patient appears to be fit for discharge then regardless of which resection they
have undergone, they should be encouraged to go home. Elderly patients, who
were often excluded from traditional ERPs, can in fact benefit enormously from
these multimodal rehabilitation programmes, . The older population are,
after all, at higher risk of cardio-respiratory complications and as such can
reap the advantages of ERPs.
The belief that ‘too early’ discharge
increases readmission rates is probably the result of attempts to adopt early
discharge policies rigidly and indiscriminately. Enhanced recovery programmes do not eliminate complications,
and do not avert anastomotic leaks.
Nevertheless, the principles of ERP can be safely applied to the
majority of patients without detriment, usually expediting the return of bowel
function and of normal physical activity.
Laparoscopic surgery lends itself to ERP
due to patients’ reduced requirement of opioid analgesia and easier
mobilisation, reduced ileus and earlier onset normal bowel function. In addition, serious complications are
easier to detect clinically in the absence of a laparotomy incision and the
pain associated with this. Hence,
after laparoscopic resection a patients’ reliance on opioid analgesia or a PCA
should be a concern and warrants investigation.
This data demonstrates the immense value of
incorporating an ERP into the management of laparoscopic colorectal patients,
and it provides objective evidence that if patients have recovered sufficiently
such that they are ready to
go home “early”, they are able to do so with the confidence that it is
safe and that their postoperative recovery is unlikely to be complicated.
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