Colorectal resection has historically been associated with complication rates as high as 38.3 percent for open surgery. At the same time, these surgeries typically bring postoperative pain, nausea, and an ileus that often leads to prolonged hospital stays. To improve postoperative outcomes and reduce length of stay, Enhanced Recovery After Surgery (ERAS) protocols – “fast-track” recovery practices – are now becoming common. Colorectal-specific protocols provide consistent recommendations for perioperative issues, such as the use of preoperative bowel preparations, nausea prevention, nasogastric tube use, early ambulation, early oral feeding, and postoperative pain control.
Dr. P. Ravi Kiran
A proponent of ERAS practices, P. Ravi Kiran, MD, Chief and Program Director of Colorectal Surgery at NewYork-Presbyterian/
“In 2020 with COVID, there was an additional need to get patients out of the hospital and minimize the need for an inpatient stay,” says Dr. Kiran, who is also the Kenneth A. Forde Professor of Surgery (in Epidemiology) at Columbia. “So, during that period, we began offering same-day colectomy to select patients following our ERAS protocols, which over the last several years have helped to reduce length of stay for many of our patients. We have less opiate use, so patients have less of an ileus, which leads to earlier recovery and earlier discharge.”
To establish the safety and feasibility of this approach, the comfort of the patient at home, and the buy-in of patients, caregivers, and surgeons themselves, Dr. Kiran led a study to evaluate patients undergoing segmental colorectal resection with anastomosis who were discharged in less than 24 hours at NewYork-Presbyterian/Columbia between October 2020 and October 2021. Patients met specific criteria, including 18 years or older, elective surgery status, categorized as an American Society of Anesthesiologist (ASA) class of <4, not on therapeutic anticoagulation, and had a favorable support system at home.
“Talking to patients about going home on the same day of surgery is a radical concept,” says Dr. Kiran. “We modeled our patient selection based on those who we thought would be good candidates to go home the same day. These included those patients who were otherwise healthy, who would be able to manage themselves at home or with help from engaged family members, and who lived reasonably close to a hospital.”
Exclusion criteria included:
- Emergency surgery
- Major medical comorbidities (ASA >4)
- Complex cases, including, ileal pouch-anal anastomosis, enterocutaneous fistula repair, re-operative pelvic surgery, or multiple complicated resections
- Surgery with ostomy creation where postoperative education was needed
- Poor patient adherence and lack of family support
All eligible patients received counseling during the preoperative surgical consultation about same-day discharge and the perioperative recovery protocol. “Traditionally, patients expect to stay in a hospital about three days or so,” says Dr. Kiran. “It’s important to inform them ahead of time that, providing they’re doing fine, we could likely discharge them the same day. We talk to them about a diet to follow at home, and typical symptoms they might have, such as abdominal bloating or nausea or pain, and what to do to circumvent them. We reduce the need for opiates by using NSAIDs, Tylenol, and Tramadol, as needed, and monitor the patients while they’re in recovery.”
“If they’re comfortable, able to walk and to eat, and if they feel that they’re ready to go home, they get discharged six to eight hours postoperatively,” continues Dr. Kiran. “If the patients feel they’re not ready, they can choose to stay until the next day when they are reevaluated again. We have found that up to one-third of our patients could be discharged within 24 hours after laparoscopic surgery.” All discharged patients received phone checks the next day and given the option for voluntary readmission if they preferred.
There were no significant differences between our same-day discharge group outcomes and the standard inpatient recovery patient outcomes, signaling that indeed same-day discharge can be safe for select patients.
— Dr. P. Ravi Kiran
The study compared patients discharged less than 24 hours postoperatively to those staying on as inpatients and to a comparable historical control group of patients for whom ambulatory surgery was not offered during October 2019 to October 2020.
The results, which were published in the online June 27, 2022, issue of Annals of Surgery, showed:
- Of 184 abdominal colorectal surgery patients, 97 had complicated colorectal resection and/or ostomy
- Of the remaining 87, 29 were discharged <24 hours postoperatively, with 7 patients discharged at 8 hours
- Of the 29 patients in the ambulatory colectomy group, there was 1 readmission on the first post-discharge day and 4 patients readmitted <30 days with ileus (1), rectal bleeding (2), and nausea/vomiting (1)
- The ambulatory colectomy group and the inpatient colectomy group had similar age, gender, race, body mass index, and comorbidity
- The inpatient colectomy group had greater estimated blood loss (109 ml vs. 34 ml) while length of stay was expectedly significantly longer (109 hours vs. 17 hours)
- No mortality in either group
- Both groups had similar rates of readmission, reoperation, anastomotic leak, ileus, and surgical site infection
- The mean length of stay for the historical control group was 83 hours
To Dr. Kiran’s knowledge, this study is one of the first of its kind presented in the United States and the first in North America to report its findings studying ambulatory colorectal resections exclusively. The Columbia researchers concluded that 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.”
Dr. Kiran and his Columbia colorectal surgical team continue to apply ERAS protocols successfully and to date, nearly 45 patients have had ambulatory colorectal surgery under these guidelines.