Actual versus estimated length of stay after colorectal surgery: which factors influence a deviation?

Prucalopride and Bowel Function Post Gastrointestinal Surgery: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Prolonged postoperative ileus (PPOI) contributes to morbidity and prolonged hospitalization. Prucalopride, a selective 5-hydroxytryptamine receptor agonist, may enhance bowel motility. This review assesses whether the perioperative use of prucalopride compared to placebo is associated with accelerated return of bowel function post gastrointestinal (GI) surgery.

METHODS

OVID, CENTRAL, and EMBASE were searched as of January 2024 to identify randomized controlled trials (RCTs) comparing prucalopride and placebo for prevention of PPOI in adult patients undergoing GI surgery. The primary outcomes were time to stool, time to flatus, and time to oral tolerance. The secondary outcomes were incidence of PPOI, length of stay (LOS), postoperative complications, adverse events, and overall costs. The Cochrane risk of bias tool for randomized trials and the Grading of Recommendations, Assessment, Development, and Evaluations framework were used. An inverse variance random effects model was used.

RESULTS

From 174 citations, 3 RCTs with 139 patients in each treatment group were included. Patients underwent a variety of GI surgeries. Patients treated with prucalopride had a decreased time to stool (mean difference 36.82 hours, 95% CI 59.4 to 14.24 hours lower, I2 = 62%, low certainty evidence). Other outcomes were not statistically significantly different (very low certainty evidence). Postoperative complications and adverse events could not be meta-analyzed due to heterogeneity; yet individual studies suggested no significant differences (very low certainty evidence).

DISCUSSION

Current RCT evidence suggests that prucalopride may enhance postoperative return of bowel function. Larger RCTs assessing patient important outcomes and associated costs are needed before routine use of this agent.

The Impact of an Enhanced Recovery Protocol in a High-Risk Population Undergoing Colon Cancer Surgery

OBJECTIVE

Enhanced Recovery ERP protocols (ERP) have improved surgical outcomes in patients undergoing elective colon cancer (CC) surgery; however, efficacy in different populations may vary. We examined the impact of an ERP in a population with high rates of obesity and multiple comorbidities.

METHODS

We performed a retrospective analysis of factors associated with postoperative complications (PoC) and length of stay (LOS) following CC surgery from 2011 to 2019 in a 5-hospital healthcare system which serves a population with higher rates of obesity (body mass index ≥30kg/m2) and multi-comorbidities, as compared to published studies. Univariable and multivariable analyses were performed.

RESULTS

A total of 408 elective CC surgery patients with complete oncologic surgical data were identified. Of these, 191 (46.81%) were under ERP. Factors independently associated with PoC included obesity (OR=1.66, P=.029), laparoscopic (OR=.52, P=.020), and hybrid (OR=.38, P=.012) versus open surgery and ASA (American Society of Anesthesiologists) class ≥3 (OR=1.98, P=.006). ERP did not impact PoC but was associated with a reduction in LOS (β=-1.02 days, 95%CI: -1.75 - -.30, P=.006). ERP had an impact on LOS in both the non-obese and obese groups (P<.001 and P=.034, respectively). PoC significantly increased LOS (β=6.67 days, 95%CI: 5.41-7.03, P<.001).

CONCLUSIONS

Following elective CC surgery, obesity and medical comorbidities were associated with increased PoC and in turn, as expected, increased LOS. ERP was associated with a reduction in LOS in both obese and non-obese patients. In high-risk populations, application of ERP may be particularly important to optimize surgical outcomes following CC surgery.

Proof-of-concept for intervention to prevent post-operative ileus in patients undergoing ileostomy formation

Background

Preventing post-operative ileus (POI) is important given its associated morbidity and increased cost of care. The authors’ prior work showed that POI in patients with newly created ileostomies is associated with a post-operative day (POD) 2 net fluid balance of > + 800 mL. The purpose of this study was to conduct an initial assessment of the efficacy of a pilot intervention.

Methods

This is a single-institution, pre–post-intervention, proof-of-concept study conducted on the Colorectal Surgery service at the University of California, San Francisco. The study included 58 procedures with ileostomy formation by board-certified colorectal surgeons between August 13, 2020 and June 1, 2021. The intervention included three adjustments to the standard Enhanced Recovery After Surgery protocol: addition of diuresis, delay in advancement to solid food, and earlier stoma intubation. Demographics, intraoperative factors, post-operative fluid balance, and outcomes (POI, post-procedure length of stay [LOS], hospitalization cost, and re-admissions) were compared between patients pre- and post-intervention.

Results

Eight (13.8%) of the 58 procedures in the intervention period were associated with POI vs. a baseline POI rate of 32.6% (p = 0.004). Compared to patients without intervention, those with intervention had 67% less odds of POI (OR 0.33, 95% CI 0.15–0.73, p = 0.01). This difference remained significant when adjusted for age, gender, body mass index, procedure duration, and operative approach (adjusted OR 0.32, 95% CI 0.14–0.72, p = 0.01). Average POD2 stoma output was 0.3 L greater (1.1 L vs. 0.8L; p < 0.001) and net fluid balance was 1.8 L lower (+ 0.3 L vs. + 2.1 L; p < 0.00001) for these 58 cases. Average post-procedure LOS was 1.9 days lower (5.3 vs. 7.2 days, p < 0.001) and direct cost was $5561 lower ($21,652 vs. $27,213, p = 0.004), with no difference in 30-day readmissions (p = 0.43).

Conclusions

This pilot intervention shows promise for reduction in POI in patients with newly created ileostomies. Additional assessment is needed to confirm these initial findings.

Effect of implementation of enhanced recovery after surgery (ERAS) protocol and risk factors on 3-year survival after colorectal surgery for cancer-a retrospective cohort of 1001 patients

PURPOSE

Several recent studies have shown that the enhanced recovery after surgery (ERAS) protocol reduces morbidity and mortality and shortens the length of stay compared to conventional recovery strategy (pre-ERAS). The aim of this study was to evaluate the effect of the implementation of this protocol on 3-year overall survival and postoperative outcome in patients undergoing colorectal resection for cancer.

METHODS

This was a retrospective, single-center, comparative, and non-randomized study. Between January, 2005, and December, 2017, 1001 patients were included (ERAS, n = 497; pre-ERAS, n = 504).

RESULTS

The 3-year overall survival rate was significantly better for ERAS than for pre-ERAS patients (76.1 vs 69.2%; p = 0.017). The length of hospital stay (median 10 days vs 15; p =  ≤ 0.001) and the 90-day readmission rate (15 vs 20%; p = 0.037) were significantly lower in the ERAS group. Three-year recurrence-free survival (p = 0.398) and 90-day complications (p = 0.560) were similar in the two groups. Analysis of 3-year survival by a multivariate Cox model identified ERAS as a protective factor with a 30% reduction in the risk of death: (HR = 0.70 [0.55-0.90]).

CONCLUSION

The implementation of the ERAS protocol was associated with an improvement in 3-year survival, a reduction of the length of hospital stay and the rate of readmission. ERAS is associated with better 3-year survival, independent of other commonly considered parameters. An ASA score > 2, smoking, a history of cancer, and atrial fibrillation are deleterious risk factors linked to earlier mortality.

Risk factors and outcomes associated with postoperative ileus following ileostomy formation: a retrospective study

Background

Postoperative ileus (POI) is associated with increased patient discomfort, length of stay (LOS), and healthcare cost. There is a paucity of literature examining POI in patients who have an ileostomy formed at the time of surgery. We aimed to identify risk factors for and outcomes associated with POI following ileostomy formation.

Methods

We included 261 consecutive non-emergent cases that included formation of an ileostomy by a board-certified colorectal surgeon at our institution from July 1, 2015, to June 30, 2020. Demographic, clinical, and intraoperative factors associated with increased odds of POI were evaluated. Post-procedure LOS, hospitalization cost, and re-admissions between patients with and without POI were compared.

Results

Out of 261 cases, 85 (32.6%) were associated with POI. Patients with POI had significantly higher body mass index (BMI) than those without POI (26.6 kg/m² vs. 24.8kg/m²; p = 0.01). Intraoperatively, patients with POI had significantly longer procedure duration than those without POI (313 min vs. 279 min; p = 0.02). Patients with POI had a significantly higher net fluid balance at postoperative day (POD) 2 than those without POI (+ 2.65 L vs. + 1.80 L; p = 0.004), with POD2 fluid balance greater than + 807 mL (determined as the maximum Youden index for sensitivity over 80%) associated with a higher rate of POI (p = 0.006). This difference remained significant when adjusted for age, gender, BMI, pre-operative opioid use, procedure duration, and operative approach (p = 0.01). Patients with POI had significantly longer LOS (11.40 days vs. 5.12 days; p < 0.001) and direct cost of hospitalization ($38K vs. $22K; p < 0.001).

Conclusions

Minimizing fluid overload, particularly in the first 48 h after surgery, may be a strategy to reduce POI in patients undergoing ileostomy formation, and thus decrease postoperative LOS and hospitalization cost. Fluid restriction, diuresis, and changes in diet advancement or early stoma intubation should be considered measures that may improve outcomes and should be studied more intensively.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland

BACKGROUND

Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland.

METHODS

A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant.

RESULTS

Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age.

CONCLUSION

These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

The Hidden Pandemic: the Cost of Postoperative Complications

Purpose of Review

Population-based increases in ageing and medical co-morbidities are expected to substantially increase the incidence of expensive postoperative complications. This threatens the sustainability of essential surgical care, with negative impacts on patients' health and wellbeing.

Recent Findings

Identification of key high-risk areas, and implementation of proven cost-effective strategies to manage both outcome and cost across the end-to-end journey of the surgical episode of care, is clearly feasible. However, good programme design and formal cost-effectiveness analysis is critical to identify, and implement, true high value change.

Summary

Both outcome and cost need to be a high priority for both fundholders and clinicians in perioperative care, with the focus for both groups on delivering high-quality care, which in itself, is the key to good cost management.

Defining Anastomotic Leaks After Colorectal Surgery: Results of a National Survey

BACKGROUND

Anastomotic leaks are a dreaded complication after colorectal surgery. Although anastomotic leak is often used as a metric to compare patient outcomes, a standard definition does not exist.

MATERIALS AND METHODS

A web-based survey was developed and distributed to US surgeons. Respondents were queried on the definition of anastomotic leaks using a 5-point Likert scale to rate different scenarios related to colorectal surgery.

RESULTS

Of potential 2209 respondents, 649 (29%) responded to the survey. The majority of respondents was men (76%) and practiced colon and rectal surgery as their primary specialty (89%). Contrast extravasation at the anastomosis, regardless of timing related to the surgery, is the clinical scenario with greatest consensus (>85%). 50% of surgeons do not believe that an abscess near the anastomosis in an asymptomatic patient defines a leak.

CONCLUSIONS

These results highlight the pressing need for standardization of the anastomotic leak definition given the implications on outcomes measurement, research trials, and health care reimbursement.

Hospital characteristics, rather than surgical volume, predict length of stay following colorectal cancer surgery

OBJECTIVE

Length of hospital stay (LOS) is considered a vital component for successful colorectal surgery treatment. Evidence of an association between hospital surgery volume and LOS has been mixed. Data modelling techniques may give inconsistent results that adversely impact conclusions. This study applied techniques to overcome possible modelling drawbacks.

METHOD

An additive quantile regression model formulated to isolate hospital contextual effects was applied to every colorectal surgery for cancer conducted in Victoria, Australia, between 2005 and 2015, involving 28,343 admissions in 90 Victorian hospitals. The model compared hospitals' operational efficiencies regarding LOS.

RESULTS

Hospital LOS operational efficiencies for colorectal cancer surgery varied markedly between the 90 hospitals and were independent of volume. This result was adjusted for pertinent patient and hospital characteristics.

CONCLUSION

No evidence was found that higher annual surgery volume was associated with lower LOS for patients undergoing colorectal cancer surgery. Our model showed strong evidence that differences in LOS efficiency between hospitals was driven by hospital contextual effects that were not predicted by provider volume. Further study is required to elucidate these inherent differences between hospitals. Implications for public health: Our model indicated improved efficiency would benefit the patient and medical system by lowering LOS and reducing expenditure by more than $3 million per year.

Pharmacist involvement to improve patient outcomes in lower gastrointestinal surgery: a prospective before and after study

Background Enhanced recovery pathways were first introduced in the UK in 2002 (Enhanced Recovery Partnership Programme in Delivering enhanced recovery-helping patients to get better sooner after surgery. Department of Health, London, 2010). The aims of such pathways are to reduce patient length of stay whilst still providing high quality of care. Objectives To evaluate the impact of pharmacist involvement in enhanced recovery pathways. Setting A large 1200 bed tertiary hospital in the North of England. Methods The pre-post study included all patients admitted for major colorectal surgery during the period 2013-2016. Baseline data were collected on all patients seen pre-operatively in a nurse-led pre-admission clinic. The intervention was introduced where a dedicated surgical pharmacist pre-operatively reviewed patients from the time they were listed for surgery until discharge with a focus on medicines optimisation. Main outcome measure The primary outcome measures were length of stay along with the type and number of post-operative complications. Results 100 patients were included in this study, with 50 patients in the baseline group and 50 patients in the intervention group. There was a significant reduction in the median length of stay (baseline group-10.5 days; intervention group-7.5 days; P < 0.001). The total number of complications was also less in the intervention group (baseline group-125; intervention group-75; P > 0.05) as was the number of patients whom had no complications (P > 0.05). Conclusions Active pharmacist involvement in enhanced recovery protocols is associated with a significantly reduced median length of stay as well as an overall reduction in the total number of post-operative complications.

Multistate modelling to estimate excess length of stay and risk of death associated with organ/space infection after elective colorectal surgery

BACKGROUND

Accounting for time-dependency and competing events are strongly recommended to estimate excess length of stay (LOS) and risk of death associated with healthcare-associated infections.

AIM

To assess the effect of organ/space (OS) surgical site infection (SSI) on excess LOS and in-hospital mortality in patients undergoing elective colorectal surgery (ECS).

METHODS

A multicentre prospective adult cohort undergoing ECS, January 2012 to December 2014, at 10 Spanish hospitals was used. SSI was considered the time-varying exposure and defined as incisional (superficial and deep) or OS. Discharge alive and death were the study endpoints. The mean excess LOS was estimated using a multistate model which provided a weighted average based on the states patients passed through. Multivariate Cox regression models were used to assess the effect of OS-SSI on risk of discharge alive or in-hospital mortality.

FINDINGS

Of 2778 patients, 343 (12.3%) developed SSI: 194 (7%) OS-SSI and 149 (5.3%) incisional SSI. Compared to incisional SSI or no infection, OS-SSI prolonged LOS by 4.2 days (95% confidence interval (CI): 4.1-4.3) and 9 days (8.9-9.1), respectively, reduced the risk of discharge alive (adjusted hazard ratio (aHR): 0.36 (95% CI: 0.28-0.47) and aHR: 0.17 (0.14-0.21), respectively), and increased the risk of in-hospital mortality (aHR: 8.02 (1.03-62.9) and aHR: 10.7 (3.7-30.9), respectively).

CONCLUSION

OS-SSI substantially extended LOS and increased risk of death in patients undergoing ECS. These results reinforce OS-SSI as the SSI with the highest health burden in ECS.

Effect of Diagnosis on Outcomes in the Setting of Enhanced Recovery Protocols

BACKGROUND

Implementation of enhanced recovery protocols in colectomy reduces length of stay and morbidity, but it remains unknown whether benefits vary by clinical diagnosis.

OBJECTIVE

Outcomes after colectomy in the setting of enhanced recovery protocols were compared for 3 diagnoses: 1) neoplasm, 2) diverticulitis, and 3) IBD.

DESIGN

This was a retrospective registry-based cohort study.

SETTINGS

Novel enhanced recovery variables were released in the American College of Surgeons National Surgical Quality Improvement Program in 2014.

PATIENTS

Patients with enhanced recovery variable data undergoing elective colectomy (July 2014 to December 2015) for neoplasm, diverticulitis, or IBD were included.

MAIN OUTCOME MEASURES

The primary outcome of interest was prolonged length of stay. Additional outcomes included surgical site infection, death/serious morbidity, reoperation, readmission, and days to achieve per os pain control, tolerance of a diet, and return of bowel function.

RESULTS

We identified 4620 patients with neoplasm, 1730 patients with diverticulitis, and 593 patients with IBD. Patients undergoing colectomy for IBD were more likely to have prolonged length of stay (OR, 1.98; 95% CI, 1.46-2.69), death/serious morbidity (OR, 1.62; 95% CI, 1.13-2.32), and readmission (OR, 1.54; 95% CI, 1.15-2.08) compared with patients with neoplasm. Patients with IBD took longer than patients with neoplasm or diverticulitis to achieve per os pain control (mean, 4.2 days vs 3.4 and 3.5 days, p < 0.001) and tolerate a diet (mean, 4.1 days vs 3.7 and 3.5 days, p < 0.001). No statistically significant differences in outcomes between patients with neoplasm and diverticulitis were seen.

LIMITATIONS

There may be heterogeneity among implemented enhanced recovery protocols.

CONCLUSIONS

Patients undergoing colectomy for neoplasm and diverticulitis have improved outcomes in comparison with patients undergoing colectomy for IBD. Knowledge of expected outcomes for patients with different diagnoses may inform clinician and patient expectations. See Video Abstract at http://links.lww.com/DCR/A623.

Risk Factors for Postoperative Ileus after Scoliosis Surgery

INTRODUCTION

One complication after scoliosis surgery is ileus; however, few reports have described the frequency of and risk factors for this complication. We conducted a retrospective clinical study with logistic regression analysis to confirm the frequency of and risk factors for ileus after scoliosis surgery.

METHODS

After a retrospective review of data from patients who underwent surgical correction of spinal deformity from 2009 to 2014, 110 cases (age range, 4-73 yr; median, 14 yr) were included in the study. We defined postoperative ileus (POI) as a surgical complication characterized by decreased intestinal peristalsis and the absence of stool for more than 3 days postoperatively. Various parameters were compared between patients with POI and those without POI. Logistic regression analysis was performed to assess the risk factors associated with ileus; a P value of <0.05 was considered statistically significant.

RESULTS

Fifteen of 110 (13.6%) cases developed POI. The median height, weight, operation time, and blood loss volume of the patients with versus without POI were 146 versus 152 cm, 39.0 versus 44.0 kg, 387 versus 359 min, and 1590 versus 1170 g, respectively. There were no significant differences between patients with versus without POI in the measured parameters, with the exception of patient height, bed rest period, and presence of neuromuscular scoliosis. Multiple logistic regression analysis revealed neuromuscular scoliosis as a significant risk factor for POI (odds ratio, 4.21; 95% CI, 1.23-14.40).

CONCLUSIONS

Our findings indicate a high probability of POI after scoliosis surgery, with an incidence of 13.6%. Neurogenic scoliosis, but not lowest instrumented vertebra or correction rate, was a risk factor for POI after scoliosis surgery. Digestive symptoms should be carefully monitored after surgery, particularly in patients with neuromuscular scoliosis.

Postoperative ileus in an enhanced recovery pathway-a retrospective cohort study

PURPOSE

Enhanced recovery after surgery (ERAS) protocols advocate no nasogastric tubes after colorectal surgery, but postoperative ileus (POI) remains a challenging clinical reality. The aim of this study was to assess incidence and risk factors of POI.

METHODS

This retrospective analysis included all consecutive colorectal surgical procedures since May 2011 until November 2014. Uni- and multivariate risk factors for POI were identified by multiple logistic regression and functional and surgical outcomes assessed.

RESULTS

The study cohort consisted of 513 consecutive colorectal ERAS patients. One hundred twenty-eight patients (24.7%) needed postoperative reinsertion of nasogastric tube at the 3.9 ± 2.9 postoperative day. Multivariate analysis retained the American Society of Anesthesiologists group 3-4 (odds ratio (OR) 1.3; 95% CI 1-1.8, p = 0.043) and duration of surgery of >3 h (OR 1.3; 95% CI 1-1.7, p = 0.047) as independent risk factors for POI. Minimally invasive surgery (OR 0.6; 95% CI 0.5-0.8, p ≤ 0.001) and overall compliance of >70% to the ERAS protocol (OR 0.7; 95% CI 0.6-1, p = 0.031) represented independent protective factors. POI was associated with respiratory (23 vs. 5%, p ≤ 0.001) and cardiovascular (16 vs. 3%, p ≤ 0.001) complications.

CONCLUSIONS

POI was frequent in the present study. Overall compliance to the ERAS protocol and minimally invasive surgery helped to prevent POI, which was significantly correlated with medical complications.

Alvimopan Use, Outcomes, and Costs: A Report from the Surgical Care and Outcomes Assessment Program Comparative Effectiveness Research Translation Network Collaborative

BACKGROUND

Randomized trials have found that alvimopan hastens return of bowel function and reduces length of stay (LOS) by 1 day among patients undergoing colorectal surgery. However, its effectiveness in routine clinical practice and its impact on hospital costs remain uncertain.

STUDY DESIGN

We performed a retrospective cohort study of patients undergoing elective colorectal surgery in Washington state (2009 to 2013) using data from a clinical registry (Surgical Care and Outcomes Assessment Program) linked to a statewide hospital discharge database (Comprehensive Hospital Abstract Reporting System). We used generalized estimating equations to evaluate the relationship between alvimopan and outcomes, and adjusted for patient, operative, and management characteristics. Hospital charges were converted to costs using hospital-specific charge to cost ratios, and were adjusted for inflation to 2013 US dollars.

RESULTS

Among 14,781 patients undergoing elective colorectal surgery at 51 hospitals, 1,615 (11%) received alvimopan. Patients who received alvimopan had a LOS that was 1.8 days shorter (p < 0.01) and costs that were $2,017 lower (p < 0.01) compared with those who did not receive alvimopan. After adjustment, LOS was 0.9 days shorter (p < 0.01), and hospital costs were $636 lower (p = 0.02) among those receiving alvimopan compared with those who did not.

CONCLUSIONS

When used in routine clinical practice, alvimopan was associated with a shorter LOS and limited but significant hospital cost savings. Both efficacy and effectiveness data support the use of alvimopan in routine clinical practice, and its use could be measured as a marker of higher quality care.