Ambulatory colectomy: A pilot protocol for same day discharge in minimally invasive colorectal surgery

Curfman, Karleigh R.; Poola, Ashwini S.; Blair, Gabrielle E.; Kosnik, Callan L.; Pille, Sunshine A.; Thilo, Evan L; Hawkins, Melinda; Rashidi, Laila

doi:10.1016/j.amjsurg.2022.04.039

Cited by 26 publications

(37 citation statements)

References 12 publications

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“…The majority of patients felt that they were active decision makers in their care and discharge, and they reported a heightened level of patient and family comfort with discharge. Over 95% of patients reported that they felt comfortable and safe with the preoperative education they received regarding SDD as well as with the instructions they were provided on discharge [ 51 ].…”

Section: Preliminary Results With Sdd Crs: the Us And Canadian Experi...mentioning

confidence: 99%

Same day discharge following elective, minimally invasive, colorectal surgery

et al. 2022

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Background As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay. Methods Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020–2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes. Results Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing. Conclusions The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

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Section: Preliminary Results With Sdd Crs: the Us And Canadian Experi...mentioning

confidence: 99%

Same day discharge following elective, minimally invasive, colorectal surgery

et al. 2022

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“…Some of the well-established advancements include: decreases in length of stay, complication rates, and opiate pain medication use, with faster return of oral intake and bowel function, and an increase in patient satisfaction [ 1 , 2 , 7 – 13 ]. With recognition of the progress the protocols have made, our institution elected to further augment the protocols and adopt them into an SDD colorectal surgery platform [ 21 ]. When building our SDD protocol, we recognized that many important factors from previously reported ERAS protocols were essential to patient success and would remain stable, while others could be expanded upon for further benefit [ 2 , 11 , 12 ].…”

Section: Introductionmentioning

confidence: 99%

“…Additionally, prior to embarking on such a significant endeavor, our institution realized two key factors that would be essential to the success of SDD. First, we recognized that upgrades to our institutional ERAS protocol would be required throughout all perioperative phases of care [ 21 ]. Compared to previously published literature, this paper details a phase by phase analysis of ERAS components and how to expand upon them to create a SDD protocol [ 21 ].…”

Section: Introductionmentioning

confidence: 99%

“…First, we recognized that upgrades to our institutional ERAS protocol would be required throughout all perioperative phases of care [ 21 ]. Compared to previously published literature, this paper details a phase by phase analysis of ERAS components and how to expand upon them to create a SDD protocol [ 21 ]. Second, we acknowledged that the success of our SDD protocol would be limited without significant patient and family education, cooperation, and understanding [ 21 ].…”

Section: Introductionmentioning

confidence: 99%

“…ERAS protocols have elaborated upon multiple factors to discuss with patients prior to their procedure, including ileostomy teaching, importance of dehydration avoidance, expected milestones, and discharge criteria [ 2 , 11 , 12 ]. Our SDD protocol adopted this concept and expanded it even further to ensure not only adequate patient understanding, but also the understanding of their home support system [ 21 ]. Both patients and their support systems were extensively educated by the physician at preoperative appointments on the aforementioned factors, as well as the procedure, the risks, the benefits, the potential SDD, and the aspects that would lead to overnight or prolonged admission.…”

Section: Introductionmentioning

confidence: 99%

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Ambulatory colectomy: a pathway for advancing the enhanced recovery protocol

et al. 2022

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Enhanced recovery after surgery (ERAS) protocols employ multiple factors to decrease surgical stress and improve recovery (Lyon et al., World J Gastroenterol 18(40):5661–5663, 2012). These protocols use multimodal approaches to improve outcomes, including length of stay and morbidities (Lyon et al., World J Gastroenterol 18(40):5661–5663, 2012; Carmichael et al., Dis Colon Rectum 60:761–784, 2017). The ERAS guidelines have evolved since development; however, the question is posed of how to improve next (Lyon et al., World J Gastroenterol 18(40):5661–5663, 2012). With the success of ERAS, in combination with milestones made by minimally invasive surgery (MIS), it is our aim to describe the next step of same day discharge colectomy. Retrospective review was performed on all colectomies from February 2019 to January 2022. Same day discharge (SDD) was defined as admission less than 23 h and no overnight stay. Procedures were nonemergent and MIS. Patients were candidates SDD based on comorbidities, communication means, and social support. SDD candidacy continued if surgery was uncomplicated. Next, patients were required to achieve strict Post Anesthesia Care Unit (PACU) criteria for discharge. SDD patients were monitored via calls or messages until their first appointment. After analysis, 326 total colectomies were identified; based on inclusion and exclusion criteria, 115 patients underwent SDD, 35.3%. Of the 115 SDD, 5 patients returned to the emergency department, only 1 required readmission (0.9%). The most performed procedures were low anterior resection, 61 (53.0%), and right hemicolectomy, 25 (21.7%). Using ERAS protocols as a groundwork to improve upon, we identified several ways to advance select patients into SDD. Using strict patient selection, intraoperative regulations, and rigorous postoperative criteria, we found that SDD as an advancement of ERAS is a relatively safe procedure with minimal complications.

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Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic

et al. 2023

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ImportanceThe American College of Surgeons (ACS) has advocated for the expansion of outpatient surgery to conserve limited hospital resources and bed capacity, while maintaining surgical throughput, during the COVID-19 pandemic.ObjectiveTo investigate the association of the COVID-19 pandemic with outpatient scheduled general surgery procedures.Design, Setting, and ParticipantsThis multicenter, retrospective cohort study analyzed data from hospitals participating in the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from January 1, 2016, to December 31, 2019 (before COVID-19), and from January 1 to December 31, 2020 (during COVID-19). Adult patients (≥18 years of age) who underwent any 1 of the 16 most frequently performed scheduled general surgery operations in the ACS-NSQIP database were included.Main Outcomes and MeasuresThe primary outcome was the percentage of outpatient cases (length of stay, 0 days) for each procedure. To determine the rate of change over time, multiple multivariable logistic regression models were used to assess the independent association of year with the odds of outpatient surgery.ResultsA total of 988 436 patients were identified (mean [SD] age, 54.5 [16.1] years; 574 683 women [58.1%]), of whom 823 746 underwent scheduled surgery before COVID-19 and 164 690 had surgery during COVID-19. On multivariable analysis, the odds of outpatient surgery during COVID-19 (vs 2019) were higher in patients who underwent mastectomy for cancer (odds ratio [OR], 2.49 [95% CI, 2.33-2.67]), minimally invasive adrenalectomy (OR, 1.93 [95% CI, 1.34-2.77]), thyroid lobectomy (OR, 1.43 [95% CI, 1.32-1.54]), breast lumpectomy (OR, 1.34 [95% CI, 1.23-1.46]), minimally invasive ventral hernia repair (OR, 1.21 [95% CI, 1.15-1.27]), minimally invasive sleeve gastrectomy (OR, 2.56 [95% CI, 1.89-3.48]), parathyroidectomy (OR, 1.24 [95% CI, 1.14-1.34]), and total thyroidectomy (OR, 1.53 [95% CI, 1.42-1.65]). These odds were all greater than those observed for 2019 vs 2018, 2018 vs 2017, and 2017 vs 2016, suggesting that an accelerated increase in outpatient surgery rates in 2020 occurred as a consequence of COVID-19, rather than a continuation of secular trends. Despite these findings, only 4 procedures had a clinically meaningful (≥10%) overall increase in outpatient surgery rates during the study period: mastectomy for cancer (+19.4%), thyroid lobectomy (+14.7%), minimally invasive ventral hernia repair (+10.6%), and parathyroidectomy (+10.0%).Conclusions and RelevanceIn this cohort study, the first year of the COVID-19 pandemic was associated with an accelerated transition to outpatient surgery for many scheduled general surgical operations; however, the magnitude of percentage increase was small for all but 4 procedure types. Further studies should explore potential barriers to the uptake of this approach, particularly for procedures that have been shown to be safe when performed in an outpatient setting.

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Ambulatory colectomy: A pilot protocol for same day discharge in minimally invasive colorectal surgery

Cited by 26 publications

References 12 publications

Same day discharge following elective, minimally invasive, colorectal surgery

Same day discharge following elective, minimally invasive, colorectal surgery

Ambulatory colectomy: a pathway for advancing the enhanced recovery protocol

Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic

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