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ERA(S) laparoscopic colorectal resection is safe & does not lead to an increased readmission rate

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11/12/2011

 Enhanced Recovery after laparoscopic colorectal resection with primary anastomosis; accelerated discharge is safe and does not give rise to increased readmission rates.

 

 KJ Gash, GL Greenslade, AR Dixon

Frenchay Hospital, North Bristol NHS Trust, UK, BS16 1L

 

Abstract

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 surgery. 

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?

Patients 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.



Introduction

Enhanced recovery programmes (ERP) following colorectal surgery have been introduced in NHS hospitals across the UK, supported by a Department of Health ‘partnership programme’ [1].  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 [2].  Recent studies report more acceptable readmission rates of 8% following open surgery (median stay 6 days) [3] and 6% in laparoscopic surgery (median stay 5 days) [4].  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 [5].  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.

 

The pivotal 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,

 

Methods

We identified 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 [6].  .  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.

 

Peri-operative 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 [9].

 

Patients are 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 required.


Results

606 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).

 

Age was 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 resectional surgery.

 

An 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%).

 

The 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. 


Discussion

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, [10]. 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 [11].  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 resections.

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 [12].

Evidently, complications 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, [13]. 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.

 


                                            References

 

1 Department of Health.

http://www.18weeks.nhs.uk/Content.aspx?path=/achieve-and-sustain/Transforming-and-improving/enhanced-recovery/

 

2            Basse L, Hjort Jakobsen D, Billesbølle P, Werner M, Kehlet H.  A clinical pathway to accelerate recovery after colonic resection. Ann Surg. 2000 Jul;232(1):51-7.

3             Hendry PO, Hausel J, Nygren J, Lassen K, Dejong CH, Ljungqvist O, Fearon KC; Enhanced Recovery After Surgery Study Group. Determinants of outcome after colorectal resection within an enhanced recovery programme. Br J Surg. 2009 Feb;96(2):197-205.

4 Faiz O, Brown T, Colucci G, Kennedy RH. A cohort study of results following elective colonic and rectal resection within an enhanced recovery programme. Coloretal Dis 2009; 11: 366-72

 

5 Basse L, Jakobsen DH, Bardram L, Billesbolle P, Lund C, Mogensen T, Rosenburg J, Kehlet H. Functional recovery after open versus laparoscopic colonic resection: a randomised blinded study. Ann Surg 2005; 241:416-23.

 

6 SJ Lewis, M Egger, PA Sylvester and S Thomas, Early enteral feeding versus “nil by mouth” after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ, 323  (2001), pp. 773–776.

 

7 Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003; 362: 1921–1928.

 

8 ML Austrup and G Korean, Analgesic agents for the postoperative period. Opioids. Surg Clin N Am,  79  (1999), pp. 253–273.

 

9 Zafar N, Davies R, Greenslade GL, Dixon AR. The evolution of analgesia in an “accelerated”recovery programme for resectional laparoscopic colorectal surgery with anastomosis. Colorectal Dis 2010; 12: 119-24

 

10 Basse L, Thorbol JE, Lossl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004; 47: 271–277.

 

11 King P, Blazeby JM, Ewings P et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 2006; 3:300-308.

 

12 Vlug MS, Wind J, Hollmann MW. Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery. A randomized clinical trial (LAFA-study). Ann Surg. www.annalsofsurgery.com.  e pub ahead of print, May 2011.

 

13            Bardram L, Funch-Jensen P, Kehlet H. Rapid rehabilitation in elderly patients after laparoscopic colonic resection. Br J Surg 2000; 87: 1540–1545

 

 


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