Feasibility and Safety of Ambulatory Surgery as the Next Management Paradigm in Colorectal Resection Surgery

Abstract

Background: Current clinical dogma favors universal inpatient admission after colorectal resection particularly in the presence of an anastomosis. Objective: We evaluate the feasibility and safety of ambulatory surgery in carefully selected patients undergoing colorectal resection/anastomosis. Methods: Between October 2020 and October 2021, all patients undergoing colorectal resection/anastomosis meeting specific criteria {no major comorbidity [American Society of Anesthesiologist (ASA) <4], not on therapeutic anticoagulation, compliant patient/family} were counseled preoperatively for ambulatory surgery (discharge <24 h postsurgery). Complicated surgery (ileoanal pouch, enterocutaneous fistula repair, reoperative pelvic surgery, multiple resections) and/or ostomy creation (loop/end ileostomy, Hartmann’s, abdominoperineal resection) were exclusions. Discharge was at 6 to 8 hours postoperatively if all predetermined factors (no ostomy teaching needed, ambulating comfortably, tolerating diet, stable vitals, and blood-work) were met and patients were willing, or was postponed to the next day at patient request. All discharged patients received phone checks the next day with the option also given for voluntary readmission if inpatient care was preferred by patient. Patients discharged <24 hours postop (AmbC) were compared to those staying on as inpatients admitted (InpC) and also to a comparable historical (October 2019–October 2020) group when ambulatory surgery was not offered (HistC). Results: Of 184 abdominal colorectal surgery patients, 97 had complicated colorectal resection and/or ostomy. Of the remaining 87, 29 (33.3%) were discharged <24 hours postoperatively [7 (24%) patients at 8 h]. Of these 29 AmbC patients, 4 were readmitted <30 days (ileus: 1, rectal bleeding: 2, nausea/vomiting: 1), 1 readmission was on first postdischarge day, none were voluntary post phone-check. AmbC and InpC (n=58) had similar age, sex, race, body mass index, and comorbidity. InpC had greater estimated blood loss (109 vs 34 mL, P<0.001) while length of stay was expectedly significantly longer (109 vs 17 hours, P<0.001). There was no mortality in either group. AmbC and InpC had similar readmission, reoperation, anastomotic leak, ileus, and surgical site infection. Mean length of stay for HistC was 83 hours. AmbC and HistC had similar age, sex, race, body mass index, and ASA class. Complications including readmission, reoperation, anastomotic leak, ileus, and surgical site infection were also similar for AmbC and HistC. Conclusions: With careful patient selection, preoperative education, perioperative management, and postoperative follow-up, ambulatory surgery is feasible in up to a third of patients undergoing colorectal resection/anastomosis and can be performed with comparable safety to the time-honored practice of routine inpatient hospitalization. Refinements in inclusion/exclusion criteria and postoperative outpatient follow-up will allow a paradigm shift in how such patients are managed, which has huge implications f...

Twenty-four Hours Stay After Colorectal Surgery; A Systematic Review

“…All studies reported on readmission rates, but only six compared their outcomes to conventional ERAS management. 22 28 29 32 33 35 Saadat, found a significant decrease in readmission rate in the 24 hours discharge group (24 hours discharge group 6.3% versus conventional ERAS 9.3%, p < 0.001). 29 The other five studies showed comparable readmission rates between groups.…”

“…However, only five studies compared outcomes to conventional ERAS management. 24,28,32,33 None of the comparing studies showed a significant difference in complications rates. A few smaller sized studies observed no complications in their 24 hours discharge study participants.…”

“…25,26,29,31 As for type of procedures, six of the studies included all types of colorectal surgery 22,27,28,30,32 and eight studies included colectomies only. [24][25][26]29,31,[33][34][35] Seven studies assessed safety, feasibility and postoperative morbidity outcomes of twenty-four hours discharge, with or without home surveillance. [25][26][27][30][31][32][33] Seven of the studies assessed preoperative variables to identify patients who would be suitable for 24 hours discharge.…”

“…[24][25][26]29,31,[33][34][35] Seven studies assessed safety, feasibility and postoperative morbidity outcomes of twenty-four hours discharge, with or without home surveillance. [25][26][27][30][31][32][33] Seven of the studies assessed preoperative variables to identify patients who would be suitable for 24 hours discharge. 22,24,28,29,31,34,35 In-and exclusion criteria from included prospective studies are shown in ►Supplementary Table S2.…”

“…Twelve of the fourteen studies provided information on the protocol that was used in their patients. 22,[24][25][26][27][28][30][31][32][33]35 Most elements were modifications of the conventional ERAS® society recommendations. 36 These consist of preoperative consultation on expectations, minimally invasive surgery, as little as possible invasive perioperative actions, early mobi-lization, early intake and clear discharge criteria.…”