OUP accepted manuscript

Length of stay after colorectal surgery in Italy: the gap between "fit for" and "actual" discharge in a prospective cohort of 4529 cases

BACKGROUND

It is common to observe a gap between the day on which the discharge criteria are reached and the actual day of discharge after colorectal surgery. The aim of this study is to understand the reasons for this difference and its clinical impact on the overall length of stay (LOS).

METHODS

All patients enrolled in the prospective iCral3 study were analyzed regarding any difference and reason between the "fit for discharge" (FFD) and "actual discharge" (AD) dates. The association between the gap and the LOS in the whole population was then assessed through a multivariate regression model including other confounding variables.

RESULTS

The analysis included 4529 patients, with a median [IQR] LOS of 6 [4-8] days. The median [IQR] LOS was 6 [4-8] days in the no-gap group (3,910 patients, 86.3%), significantly lower (p < .001) than 7 [6-10] days in the gap group (619 patients, 13.7%). Among the gap reasons, the "need for postoperative rehabilitation" compared to "not willing to return home" and "social constraints" was associated with the longest LOS (9 [6.0-12.5] days, p < 0.001 vs other reasons). The existence of the gap independently determined a 2.3-day lengthening of LOS.

CONCLUSIONS

Among other factors, the gap between FFD and AD had an independent impact on LOS. The most frequent reasons for this gap were "not willing to return home" and "social constraint", while the "need for postoperative rehabilitation" had the greater clinical impact.

Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland

INTRODUCTION

The ERAS protocol is a set of international guidelines established to expedite patients' discharge after colorectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few, and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients' return to home at earlier rates than traditional practice.

METHODS

A prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively.

RESULTS

In total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within 24 h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative antibiotics use of preoperative gabapentin.

CONCLUSION

UHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improvement required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland.

Incidence and clinical predictors of 30-day emergency readmission after colorectal cancer surgery - A nationwide cohort study

AIM

The aim of this study was to investigate the risk and predictors of 30-day emergency readmission and surgical reintervention after discharge from colorectal cancer surgery with curative intent in Denmark.

METHOD

This is a retrospective cohort study using Danish nationwide registry data. We included all patients who underwent colorectal tumour resection with curative intent between 1 January 2005 and 1 December 2018. The primary outcome was 30-day emergency readmission, defined as any emergency hospital visit within 30 days of discharge. Secondary outcomes were 30-day emergency readmission with a minimum duration of 2 days and 30-day emergency readmission including any abdominal procedure. Twenty-three candidate predictors including patient comorbidities, tumour characteristics, surgical treatment and length of stay were evaluated using multivariate logistic regression models. Length of stay was categorized into percentiles and standardized according to year of surgery.

RESULTS

Of the 40 782 patients included in the study, 8360 (20.5%) were readmitted within 30 days of discharge. Median time to readmission was 6 days (interquartile range 2-15 days). A total of 4968 patients (12.2%) were readmitted for at least 2 days, and 793 patients (1.9%) underwent an abdominal procedure during their readmission. The strongest predictors of 30-day readmission were length of stay below the fifth percentile (OR 2.36; P < 0.001) and American Society of Anesthesiologists score IV (OR 2.21; P < 0.001).

CONCLUSION

Emergency readmission is frequent after colorectal cancer surgery with curative intent, and almost 10% of readmitted patients require surgical reintervention. An increased focus on predicting preventable readmissions might facilitate interventions to reduce morbidity and hospital expenses.

Enhanced recovery after surgery (ERAS) program in octogenarian patients: a propensity score matching analysis on the "Lazio Network" database

PURPOSE

The aim of this study was to evaluate the safety and compliance with the enhanced recovery after surgery (ERAS) protocol in octogenarian patients undergoing colorectal surgery in 12 Italian high-volume centers.

METHODS

A retrospective analysis was conducted in a consecutive series of patients who underwent elective colorectal surgery between 2016 and 2018. Patients were grouped by age (≥ 80 years vs < 80 years), propensity score matching (PSM) analysis was performed, and the groups were compared regarding clinical outcomes and the mean number of ERAS items applied.

RESULTS

Out of 1646 patients identified, 310 were octogenarians. PSM identified 2 cohorts of 125 patients for the comparison of postoperative outcomes and ERAS compliance. The 2 groups were homogeneous regarding the clinical variables and mean number of ERAS items applied (11.3 vs 11.9, p-ns); however, the application of intraoperative items was greater in nonelderly patients (p 0.004). The functional recovery was similar between the two groups, as were the rates of postoperative severe complications and 30-day mortality rate. Elderly patients had more overall complications. Furthermore, the mean hospital stay was higher in the elderly group (p 0.027). Multivariable analyses documented that postoperative stay was inversely correlated with the number of ERAS items applied (p < 0.0001), whereas age ≥ 80 years significantly correlated with the overall complication rate (p 0.0419).

CONCLUSION

The ERAS protocol is safe in octogenarian patients, with similar levels of compliance and surgical outcomes. However, octogenarian patients have a higher rate of overall complications and a longer hospital stay than do younger patients.