Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery
ABSTRACT Accelerated recovery pathways may reduce length of hospital stay after surgery but there are few data on minimally invasive colorectal operations.
An enhanced recovery pathway (ERP) was instituted, including preoperative analgesia, limited intravenous fluids and opiates, and early feeding. Intrathecal analgesia was administered as needed, but epidural analgesia was not used. The first 66 patients subjected to the ERP were case-matched by surgeon, procedure and age (within 5 years) with patients treated previously in a fast-track pathway (FTP). Short-term and postoperative outcomes to 30 days were compared.
Hospital stay was shorter with the ERP than the FTP: median (interquartile range, i.q.r.) 3 (2-3) versus 3 (3-5) days (P < 0·001). A 2-day hospital stay was achieved in 44 and 8 per cent of patients respectively (P < 0·001). Patients in the ERP had a shorter time to recovery of bowel function: median (i.q.r.) 1 (1-2) versus 2 (2-3) days (P < 0·001). Thirty-day complication rates were similar (32 per cent ERP, 27 per cent FTP; P = 0·570). Readmissions within 30 days were more common with ERP, but the difference was not statistically significant (10 versus 5 patients; P = 0·170). Total hospital stay for those readmitted was shorter in the ERP group (18 versus 23 days).
ERP decreased the length of hospital stay after minimally invasive colorectal surgery.
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ABSTRACT: Enhanced recovery pathways have been shown to decrease the length of hospital stay in patients undergoing colorectal surgery. Few reports have studied patients undergoing minimally invasive surgery for rectal cancer. Our aim was to review our experience in minimally invasive rectal cancer surgery. We report short-term outcomes and evaluate the potential advantages of the enhanced recovery protocol compared with our less intensive conventional pathway. This is a consecutive retrospective study of all minimally invasive rectal cancers treated from February 2005 to December 2011. Multivariable logistic regression models were constructed to identify factors contributing to a short length of stay. This study was performed at Mayo Clinic, Rochester, Minnesota, between 2005 and 2011. A total of 346 patients were retrospectively reviewed. Seventy-eight patients were managed under the enhanced recovery pathway. Patients underwent either laparoscopic-, robotic-, or hand-assisted laparoscopic surgery for rectal cancer. All patients followed either a standardized conventional pathway or an enhanced recovery pathway for perioperative care. The primary outcome was the length of stay. Secondary outcomes were postoperative complications and 30-day readmissions. Hospital stay was significantly decreased for patients who underwent minimally invasive surgery for rectal cancer and were managed with an enhanced recovery protocol, 4.1 days, vs 6.1 days for the conventional pathway (95% CI, -2.9 to -1.2 days; p < 0.0001). Rates of complications were similar between the 2 groups. Factors associated with shorter length of stay included the enhanced recovery protocol and laparoscopic or robotic surgery compared with hand-assisted laparoscopic surgery. This was a retrospective study at a single institution. Additional limitations include the comparison with historical controls and the potential for selection bias. The enhanced recovery pathway is associated with a significantly decreased length of hospital stay after minimally invasive surgery for rectal cancer in this series. Decreased hospital stay was achieved without affecting short-term outcomes.Diseases of the Colon & Rectum 05/2014; 57(5):557-63. DOI:10.1097/DCR.0000000000000101 · 3.20 Impact Factor
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ABSTRACT: Background The aim of the study was to assess which aspects of an enhanced recovery programme are associated with better outcomes following laparoscopic colorectal surgery.MethodsA database of laparoscopic colorectal procedures performed in 2011 was reviewed. Elements of the enhanced recovery programme and compliance were evaluated for short-term (30-day) outcomes. Individual elements included gabapentin, celecoxib, intrathecal analgesia, diet, postoperative fluids, and paracetamol/non-steroidal anti-inflammatory drug pain management.ResultsFive hundred and forty-one consecutive procedures were included. Compliance with the enhanced recovery programme elements ranged from 82·4 to 99·3 per cent. Median length of hospital stay was 3 (i.q.r. 2–5) days, with 25·9 per cent of patients discharged within 48 h. Patients without complications had a median length of stay of 3 (i.q.r. 2–4) days if compliant and 3 (3–5) days if not (P < 0·001). Low oral opiate intake (oral morphine equivalent of less than 30 mg) (odds ratio (OR) 1·97, 95 per cent confidence interval 1·29 to 3·03; P = 0·002), full compliance (OR 2·36, 1·42 to 3·90; P < 0·001) and high surgeon volume (more than 100 cases per year) (OR 1·50, 1·19 to 1·89; P < 0·001) were associated with discharge within 48 h. Compliance with the elements of oral intake and fluid management in the first 48 h was associated with a reduced rate of complications (8·1 versus 19·6 per cent; P = 0·001). Median oral opiate intake was 37·5 (i.q.r. 0–105) mg in 48 h, with 26·2 per cent of patients receiving no opiates.Conclusion Compliance with an enhanced recovery pathway was associated with less opiate use, fewer complications and a shorter hospital stay.British Journal of Surgery 07/2014; 101(8). DOI:10.1002/bjs.9534 · 4.84 Impact Factor
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ABSTRACT: Background The aim of this study was to determine factors associated with deviation in length of hospital stay (LOS) from that determined by diagnosis-related groups. Methods A cohort study from a prospectively collected database was conducted, including consecutive patients undergoing surgery in a high-volume colorectal surgery department in 2009. Results For 1,461 included patients, average expected and actual LOS were 8.17 days (interquartile range, 4.7 to 11.9 days) and 8.31 days (interquartile range, 4 to 10 days), respectively. The most prominent factors associated with an increase of LOS from expected were parenteral nutrition (5.11 days), emergency room admittance (3.67 days), and ileus (3.45 days) (P ≤ .001 for all). Other independently associated factors included blood transfusion, anastomotic leak, sepsis, pulmonary embolism, and surgeon. Patients with higher severity illness indexes and longer postoperative intensive care stay had lower than expected LOS. Conclusions After colorectal surgery, several modifiable factors are associated with deviation of LOS from expected. An opportunity hence exists to reduce both LOS and financial burden for hospitals in an era of pay for performance.The American Journal of Surgery 10/2014; 208(4):663–669. DOI:10.1016/j.amjsurg.2013.06.004 · 2.41 Impact Factor