Deborah S. Keller

Discharge within 24 to 72 Hours of Colorectal Surgery Is Associated with Low Readmission Rates when Using Enhanced Recovery Pathways

BACKGROUND Enhanced Recovery Pathways (ERPs) have demonstrated reduced hospital length of stay and improved outcomes after colorectal surgery. Concerns exist about increases in readmission rates. Laparoscopic colorectal surgery with an ERP can permit earlier discharge without compromising safety or increasing readmission rates. STUDY DESIGN A review of a prospective database was performed for major elective colorectal procedures by a single surgeon. All patients followed a standardized ERP and discharge criteria. Patients were categorized by approach and day of discharge (DoD) of ≤ 1, ≤ 2, ≤ 3, ≤ 7, and >7 days. Main outcomes measures were length of stay and 30-day readmission rates in each group. RESULTS Eight hundred and six cases (609 laparoscopic, 197 open) were identified during a 64-month period. Mean age was similar for the laparoscopic (59.1 years) and open (58.3 years) groups. Mean overall DoD was at 5 days (± 4.8 days); by approach, the mean laparoscopic DoD was at 3.9 days and open DoD was at 8.4 days. Twenty-nine percent were discharged within 48 hours (38% laparoscopic and 8% open) and 50% were discharged within 72 hours (62% laparoscopic and 19% open). Only 8.9% of all patients (n = 72) were readmitted (7.2% laparoscopic, 14.2% open). The cumulative readmission rate for laparoscopic patients in early DoD groups postoperative days 1, 2, and 3 were 0.2%, 1.6%, and 3.4%, respectively. CONCLUSIONS Combining laparoscopy with an ERP optimizes patient care in colorectal surgery. The combination permits early discharge; 38% were discharged within 2 days and 62% within 3 days of surgery, with low readmission rates. These results support that early DoD is possible without compromising patient safety or increasing readmission rates. This might be a marker for low readmission rate, and suggests that readmission rate alone might not be an adequate marker of quality.

Short-Term Outcomes for Robotic Colorectal Surgery by Provider Volume

BACKGROUND There has been a rapid increase in robotic colorectal surgery. Benefits of this technology are unclear and being investigated. However, differences in outcomes between centers have not been evaluated. Our aim was to evaluate outcomes for robotic colorectal procedures by surgeon and hospital volume. STUDY DESIGN A national inpatient database was reviewed for robotic colorectal resections performed during an 18-month period. Hospitals and surgeons were stratified into high, average, and low case volumes based on a normal distribution scale. High, average, and low volume was defined as ≤ 10, 11 to 20, and >20, respectively, for hospitals, and ≤ 5, 6 to 15, and >15, respectively, for surgeons. Short-term outcomes and hospital cost were evaluated. RESULTS There were 1,428 robotic colorectal cases across 123 hospitals and 411 surgeons evaluated. Only 13% (n = 16) of hospitals and 4.4% (n = 18) of surgeons performed a high volume of robotic colorectal cases. Lower volume was associated with significantly more overall complications (p < 0.001; p < 0.001), longer length of stay (p = 0.005; p < 0.001), and higher cost (p < 0.001; p < 0.001) at the hospital and surgeon level, respectively. High-volume hospitals and surgeons had significantly lower rates of postoperative bleeding (p < 0.001; p < 0.001) and ileus (p = 0.003; p = 0.0014). CONCLUSIONS Lower-volume providers, who are performing the majority of procedures, are generating more complications, longer hospital lengths of stay, and higher costs of care. These results have a negative impact on quality outcomes measures for those facilities. Although surgeons and hospitals continue to selectively explore robotics, this should be limited to high volume and interested surgeons and hospitals to offer high-quality outcomes to patients.

Demonstrating the Benefits of Transversus Abdominis Plane Blocks on Patient Outcomes in Laparoscopic Colorectal Surgery: Review of 200 Consecutive Cases

BACKGROUND Quality improvement in colorectal surgery (CRS) requires implementation of tools to improve patient and financial outcomes, and assessment of results. Our objective was to evaluate the durability of transversus abdominis plane (TAP) blocks and a standardized enhanced recovery protocol (ERP) on a large series of laparoscopic colorectal resections. STUDY DESIGN Two hundred consecutive laparoscopic CRS patients received TAP blocks under laparoscopic guidance at the end of their operation. All were managed with a standardized ERP. Demographic, perioperative, and postoperative outcomes variables were analyzed. The main outcomes measures were length of stay (LOS), readmission, reoperation, morbidity, and mortality rates. RESULTS Of 200 cases, 194 were elective and 6 emergent. The main diagnosis was colorectal cancer (45%). The mean patient age was 61.2 years, mean body mass index was 29.2 kg/m(2), and the majority (63%) were American Society of Anesthesiologists (ASA) class III. The main procedure performed was a segmental colectomy (64%). Mean operative time was 181 minutes. Nine cases (4.5%) were converted to open. The median LOS was 2 days (range 1 to 8 days). Twenty-one percent were discharged by postoperative day (POD) 1, 41% by POD 2, and 77% by POD 3. By POD 7, 99% were discharged. Twelve percent (n = 24) had complications, and 6.5% (n = 13) were readmitted. There were 3 unplanned reoperations and no mortalities. Comparing the first and second groups of 100 consecutive patients further tested the consistency of the TAP block benefit. With comparable demographics, there were no significant differences in readmission, complication, or reoperation rates over the entire series. CONCLUSIONS Adding TAP blocks to an ERP facilitated shorter LOS with low readmission and reoperation rates when compared to previously published series. The effect appears durable and consistent in a large case series. Transversus abdominis plane blocks may be an efficient, cost-effective method for improving laparoscopic CRS results.

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.

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). The ASCRS Clinical Practice Guidelines Committee is composed of society members who are c

Predicting the unpredictable: Comparing readmitted versus non-readmitted colorectal surgery patients

BACKGROUND To evaluate readmissions to determine predictors and patterns of readmission. METHODS Prospective database review identified readmitted and non-readmitted patients after colorectal surgery. Variables for the index and readmission episode were examined. RESULTS A total of 212 readmissions and 3,292 nonreadmissions were analyzed. The majority was elective. Readmitted patients were older (P = .003), had more comorbidities (P < .0001), longer operative times (P < .0001), length of stay (P < .0001), and higher costs (P = .002). At the time of discharge, more readmitted patients required temporary nursing (P < .0001). Independent readmission predictors were higher American Society of Anesthesiologists score, previous abdominal operation, intensive care unit stay, and dysmotility/constipation surgery. At the time of readmission, 29.2% required reoperation. More than half had an open procedure initially (55.2%). After initial open procedures, reoperative time (P = .05) and LOS were longer (P = .028), and more patients required temporary nursing care at the time of discharge (P = .046). Readmissions caused an additional mean hospital cost of

Risk prediction score in laparoscopic colorectal surgery training: experience from the English National Training Program.

12,670.89. CONCLUSIONS Readmitted patients have distinct demographic and outcomes variables. As most were elective cases, stratifying patients preoperatively may enable perioperative planning for this higher risk group.

Readmissions after ileostomy closure: cause to revisit a standardized enhanced recovery pathway?

OBJECTIVE The overall aim was to develop and validate a risk prediction score for laparoscopic colorectal surgery training cases. BACKGROUND Published risk prediction scores are not transferable between hospitals because they are derived from a single institutions data and are not designed for use in training situations. METHODS Cases from the prospectively collected database of the National Training Programme in Laparoscopic Colorectal Surgery, between July 2008 and July 2012, were analyzed. Independent risk factors for conversion were identified by the logistic regression. Converting the odds ratios into integers created a risk prediction score for conversion. The clinical impact of this score was investigated by comparing postoperative complications and the level of trainer input in high- and low-risk cases. To study whether adverse outcomes in predicted high-risk cases occur outside the National Training Programme in Laparoscopic Colorectal Surgery, 2 external data sets were examined. RESULTS A total of 2341 cases carried out in 42 hospitals were analyzed. Significant risk factors for conversion were body mass index, American Society of Anesthesiology classification, male sex, prior abdominal surgery, and resection type. At a risk score of more than 6, complication rates increased, including mortality (2.9% vs 0.5%, P < 0.001), anastomotic leak (4.3% vs 1.4%, P = 0.002), and a higher level of trainer input (32.2% vs 19.9% of cases, P < 0.001). Analysis of 786 external cases showed that high-risk cases had higher conversion (18.8% vs 7.1%, P < 0.001), overall complication (36.4% vs 15.0%, P < 0.001), and leak rates (4.0% vs 1.3%, P = 0.015). CONCLUSIONS A risk predication score to facilitate case selection in laparoscopic colorectal surgery training was developed and validated.

Indocyanine green fluorescence imaging in colorectal surgery: overview, applications, and future directions

BACKGROUND Our objective was to evaluate ileostomy reversal patients managed with a standardized enhanced recovery pathway to identify factors associated with readmissions. METHODS Prospective review database identified ileostomy reversal patients. Variables for the index admission and readmission were evaluated. RESULTS Three hundred thirty-two patients were analyzed. The primary diagnosis was colorectal cancer (57.6%). Thirteen percent of the patients were discharged by postoperative day (POD) 1, 47% by POD 2, and 65% by POD 3. The complication rate was 16.8%. The main complication was ileus/small bowel obstruction (n = 27). Thirty-day readmission rate was 12.4% (n = 41); small bowel obstruction (n = 27) was the most frequent readmission diagnosis. The median readmission POD was 7. Only 1 patient had a follow-up visit before readmission. The median readmission length of stay was 4 days. CONCLUSIONS Most ileostomy reversal readmissions occur before the first follow-up and stem from preventable causes. An enhanced recovery pathway modification may improve outcomes and utilization in this group.

Why the Conventional Parks Transanal Excision for Early Stage Rectal Cancer Should Be Abandoned.

Indocyanine green fluorescence imaging is a surgical tool with increasing applications in colorectal surgery. This tool has received acceptance in various surgical disciplines as a potential method to enhance surgical field visualisation, improve lymph node retrieval, and decrease the incidence of anastomotic leaks. In colorectal surgery specifically, small studies have shown that intraoperative fluorescence imaging is a safe and feasible method to assess anastomotic perfusion, and its use might affect the incidence of anastomotic leaks. Controlled trials are ongoing to validate these conclusions. The number of new indications for indocyanine green continues to increase, including innovative options for detecting and guiding management of colorectal metastasis to the liver. These advances could offer great value for surgeons and patients, by improving the accuracy and outcomes of oncological resections.

Multivisceral resection for advanced rectal cancer: outcomes and experience at a single institution

1211 Diseases of the Colon & ReCtum Volume 58: 12 (2015) the impetus for local excision (le) for early stage, histologically favorable rectal cancer stems from the early work by morson et al, who, in 1977, demonstrated that curative-intent le could result in equivalent oncologic outcomes when compared with radical resection. it was also borne from data obtained in the 1990s from the Cancer and leukemia Group B (CalGB) 8984, which, at the time, was the only prospective, multi-institutional study to lend credence to the concept of le for stage i rectal cancer. CalGB 8984 was a pendulum swing in the direction of organ preservation and it proposed a treatment paradigm analogous to the management of early stage breast cancer whereby the national surgical adjuvant Breast and Bowel Project-06 demonstrated that local treatment (ie, breast-conservation surgery coupled with adjuvant radiation) was equivalent to modified radical mastectomy. CalGB 8984 accrued 180 patients, and 161 underwent le for cure of early stage rectal cancer using the fullthickness circumferential bowel wall removal technique of the primary lesion with perianal, transsphincteric, or transrectal approaches. use of an advanced platform, such as transanal endoscopic microsurgery (tem), was not required, and whether it was used for any of the 161 patients who underwent curative-intent le was not reported. in this landmark study, patients with t1 cancer underwent le alone, whereas patients with t2 lesions underwent le followed by long-course external beam radiotherapy. the 6-year survival (85%) and failure-free rates (78%) for this treatment seemed acceptable, particularly during an era when local failure after standard oncologic resection with the abdominoperineal resection, in prospective series, had shown failure rates on the order of 20% to 30%. thus, le seemed to be an attractive alternative to radical resection, the latter a procedure that was more invasive, inarguably more morbid, and at the time resulted in lackluster oncologic outcomes. With the backing of CalGB 8984, and coupled with a frenzy toward minimally invasive surgical approaches that embraced the less-is-more doctrine, the rate of le for early stage rectal cancer increased at an alarming rate. however, with the passage of the decades, it became clear that le for even the most appropriately selected stage i lesions (managed with the same approach set forth by CalGB) resulted in inferior outcomes, and this even included the long-term data from CalGB that practically issued an about face on the recommendation of le for t2 cancer with adjuvant radiotherapy. meanwhile, modern rectal cancer management, with the advent of the total mesorectal excision and its eventual painstaking implementation, was proving to be oncologically effective, with local recurrence rates after standard resection alone using total mesorectal excision falling to 7.1% for stage i disease. With failures after le for cure significantly higher, it left one to ponder this question: had the original, time-tested end points of rectal cancer surgery (eg, disease-free survival and cure) been usurped by a new wave of patient-driven end points, such as quality of life (eg, stoma-free surgery, maintenance of normal bowel, and urogenital function)? more recently, with the realization that le was compromising the oncologic outcomes in the subset of patients otherwise predicted to have the highest chance for cure (ie, stage i patients), a slight deceleration in the incidence of le for rectal cancer has been observed for the first time in 30 years. even organ preservationists had questioned whether le was appropriate therapy for t1 lesions, and it did not seem appropriate that, as surgeons, we would subjugate patients to an oncologically inferior operation, where the failure rates are much higher and the outcomes observed with traditional standard resection (after the total mesorectal excision era) impart superior cure rates. however, data on le have not always been consistent, and it was conceivable that the quality of le, as governed by the technique used, may have been of more importance Why the Conventional Parks Transanal Excision for Early Stage Rectal Cancer Should Be Abandoned