Same day discharge following elective, minimally invasive, colorectal surgery

Abstract

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.

Predictive Factors for Successful Same-Day Discharge Following Minimally Invasive Colectomy and Stoma Reversal

“…SDD has demonstrated similar postoperative complications, readmissions, and reoperation rates as standardized ERPs. 3 The benefit of SDD is not solely patient-related—shorter hospital stays have the dual advantage of reduced cost and carbon footprint through decreased resource consumption. 11,12 With this incentive, we sought to determine factors that may impact successful SDD as an area of potential intervention.…”

“…1 Same-day discharge (SDD) pathways represent the evolution of ERPs by optimizing the elements of perioperative care that keep patients hospitalized after colorectal surgery. 2,3 After an initial series from France, studies from Canada and the United States have demonstrated its feasibility in different settings and with different modalities of postdischarge care. [4][5][6] The implementation of SDD protocols after colectomy requires a multifaceted approach, including advanced surgical techniques, opioid-sparing analgesia to promote return of bowel function, early remote follow-up methods, and patient-related factors.…”

“…4,5,7 Nevertheless, a proportion of intended SDD patients are unable to be discharged on the day of surgery or require an early postdischarge emergency department (ED) visit. 3 Many of the barriers to SDD implementation focus on the potential for SDD failure and/or early readmission, which may result in negative clinical and economic outcomes. 2 Identification of factors predictive of SDD success or failure may provide early “warning signs” for providers to keep patients hospitalized instead of discharged on the day of surgery, thus decreasing several of the barriers to SDD implementation by increasing the chances of success.…”

“…1 Same-day discharge (SDD) pathways represent the evolution of ERPs by optimizing the elements of perioperative care that keep patients hospitalized after colorectal surgery. 2,3 After an initial series from France, studies from Canada and the United States have demonstrated its feasibility in different settings and with different modalities of postdischarge care. 4–6…”

Having Outpatient Major Elective (HOME) Robotic Colon Resection Protocol: A Safe Approach to Ambulatory Colon Resection

“…Within the United States in the last year, several early publications have begun to be analyzed and have showed several other favorable patient outcomes such as decreased opioid use and increased patient satisfaction. 5 Deriving inspiration from the previously described French laparoscopic same-day protocols, we developed HOME for our robotic partial colectomies. We seek to further add to the rapidly growing body of evidence in the United States representing the feasibility and safety of ambulatory colectomy under a same-day ERAS protocol.…”