Two-day Hospital Stay After Laparoscopic Colorectal Surgery under an Enhanced Recovery after Surgery (ERAS) Pathway

Laparoscopic colorectal surgery is becoming the standard treatment for elective colorectal resection, increasing from 13.8 % in 2007 to 42.6 % in 2009 of all colorectal resections [1]. Although laparoscopic colorectal resection (LCR) has been associated with a short hospital stay and low morbidity, mean hospital stay rates reported vary from 4 to 15 days [2‐4]. A shorter hospital stay following colorectal surgery has been recently achieved through enhanced recovery after surgery programs (ERAS) [5, 6]. With this enhanced recovery protocol, some authors have mentioned a mean hospital stay between 3.5 and 4.5 days [7‐9] with a low morbidity rate. However, readmission rates reported are still high, reaching up to 8–30 % [10‐12]. In recent years, there has been a renewed interest in evaluating fast-track (FT) laparoscopic colorectal surgery intending to shorten hospital stay with low morbidity and readmission rates. Therefore, the aim of the present study was to examine the feasibility and safety of a two-day hospital stay after LCR in a referral center from Argentina under an ERAS protocol. A secondary outcome was to determine variables associated with a prolonged hospital stay.

There were 882 patients in the analyzed period. Mean age was 63.7 years old (±14.9), females accounted for 46.9 % of the patients, and the mean BMI was 26 kg/m² (±4.4). Group A represented 10.3 % of the patients in this series (91 patients). Additional demographic characteristics are shown in Table 2. There were no differences regarding age, gender, BMI, ASA, and previous abdominal surgeries between groups. The most common diagnosis of the overall population was colon cancer/polyp (55.8 %), followed by rectal cancer (16.5 %) and diverticular disease (13 %). The intraoperative data are shown in Table 3. The most frequent operations performed were sigmoidectomy (n = 135, 15 %), left colectomy (n = 133, 15 %), right colectomy (n = 128, 14.5 %), high anterior resection (n = 74, 8.4 %), low anterior resection (n = 48, 5.4 %), ultra-low anterior resection (n = 76, 8.6 %), and abdominoperineal resection (APR) (n = 11, 1.2 %). Group A had a lower incidence of rectal cancer and anterior resections than group B (6.6 vs. 17.7 % [p = 0.006] and 14.3 vs. 23.4 % [p = 0.048], respectively), and a lower mean operative time (170 vs. 192 min; p = 0.002). Table 4 shows postoperative outcomes. The median hospital stay was 3 days and there were no postoperative deaths in this series. Regarding postoperative morbidity, the overall morbidity rate was 15.6 % (139 patients), but 68 % of affected patients (n = 94) had minor complications (Dindo–Clavien classification 1, 2, or 3a). There were 150 postoperative complications with 123 (13.9 %) surgical complications and 27 (3 %) general complications among 882 patients. The most common surgical complication was postoperative ileus (49 patients) followed by wound infection (20 patients). Compared to group B, group A had a lower overall morbidity rate (5.5 vs. 16.9 %, respectively; p = 0.004) and a lower incidence of surgery-related complications (5.5 vs. 14.9 %, respectively; p = 0.001). Postoperative ileus was more frequent in group B than in group A (6 vs. 0 %, respectively; p = 0.02). None of the patients (0 %) in group A had general complications, whereas 27 patients (3.4 %) in group B had them (p = 0.07). Univariate analyses showed that male gender, preoperative comorbidities, and ASA score III–IV were associated with higher incidence of postoperative complications.

The overall conversion rate in this series was 10 % (86 patients). Only one patient in group A required conversion; thus when compared with group B, group A had a lower incidence of conversion (1.2 vs. 10.7 %; p = 0.003). The overall readmission rate was 4.4 % (39 patients); there were no readmissions in group A. Although readmission rate in group A was lower than in group B (0 vs. 4.9 %) this difference had no statistical significance (p = 0.089). Another finding of the univariate analyses was that patients with BMI >30 and low anterior resection had a higher readmission rate (8.5 vs. 3.7 % [p = 0.049] and 12.5 vs. 4 % [p = 0.019], respectively). Thirty-seven patients underwent reoperation. None of the patients in group A required reoperation, whereas the reoperation rate in group B was 4.7 % (p = 0.035). Indications for reoperation were peritonitis in 12 patients (32 %), intestinal occlusion in 11 patients (29 %), postoperative bleeding in 6 patients (16 %), anastomotic leak in 4 patients (10 %), intra-abdominal abscess in 2 patients (5 %), acute laparotomy dehiscence in 1 patient (2 %), and intestinal ischemia 1 patient (2 %).

Multivariate analysis showed that conversion, postoperative morbidity, and rectal prolapse were independently associated with a 2-day hospital stay, after adjusting for age, gender, BMI <30, ASA III-IV, rectal polyp/cancer, anterior resection, operative time, and colonic perforation after colonoscopy (CPAC) (Table 5).

Despite the fact that LCRs allow an earlier recovery and discharge from hospital, a short hospital stay has not been routinely achieved [10]. Moreover, some authors have reported short hospital stays after open colorectal surgery when combining fast-track or multimodal recovery programs. In this regard, Behrns et al. [16] and Delaney et al. [17] reported a mean hospital stay of 4.4 and 3.5 days, respectively, after open surgery. Basse et al. [7] pushed these results further and reported 2-day hospital stays in a randomized trial comparing open versus laparoscopic surgery, showing no differences between groups. However, morbidity and readmission rates reported reached up to 27 and 12 %, respectively. In accordance with these data, Andersen et al. [18] mentioned a decrease in the readmission rate from 20.1 to 11.3 % when comparing patients with a 2-day versus a 3-day planned hospital stay. On the other hand, the LAFA study compared postoperative outcomes in four groups (2 laparoscopic and 2 open colectomy groups with and without an FT program). The median hospital stay of patients undergoing laparoscopic surgery with FT care was shorter than the other groups (laparoscopic/FT: 5 days, open/FT: 7 days, laparoscopic/standard: 6 days, and open/standard: 7 days (p < 0.001). However, there were no differences among groups regarding postoperative morbidity and mortality, reoperation and readmission rates, and quality of life at 2 and 4 weeks. The authors concluded that the optimal operative treatment for patients requiring segmental colectomy for colon tumor resection is laparoscopic embedded in a FT program or accelerated recovery [19]. A recent report from Delaney et al. [10] mentioned an overall readmission rate of 8.5 %, with 5.4 and 7.7 % after a 2 and 3-day hospital stay, respectively, in a series of 118 patients treated laparoscopically. However, this represents a single-institution series and additional data are needed. In the same way, Levy et al. [20] reported a series of 10 patients who underwent LCR with a 23 h hospital stay and no readmissions.

The results presented in this study bring new evidence supporting feasibility and safety of short hospital stays following LCR. Our series of 882 patients shows a median hospital stay of 3 days, with 10 % of patients discharged within the first 48 h. Readmission rates were 0 % for patients discharged on the second postoperative day and 4.9 % for patients who stayed longer than 2 days. Moreover, patients discharged within 48 h after surgery had lower morbidity and reoperation rates. Of course early discharge does not determine a lower morbidity, reoperation, and readmission rates, and it is likely these findings are related to several variables, including patient factors and disease factors, surgical experience, and procedure-specific issues. However, it allows patients who are recovering well from surgery on the second postoperative day to have a better chance of not having postoperative complications. Thus, colorectal surgeons should try to identify these patients in order to provide optimal postoperative care with appropriate efficiency. Therefore, FT recovery programs and standardized discharge criteria are of the utmost importance.

In our series, patients discharged on the second postoperative day had a lower mean operative time, a lower incidence of rectal cancer, and hence, a lower incidence of anterior resection. There were no differences between groups A and B regarding high and ultra-low anterior resections (8.8 vs. 8.3 % [p = 0.9] and 4.4 vs. 9.1 % [p = 0.12], respectively). However, compared to group B, group A had a lower proportion of low anterior resections (5.9 vs. 1.1 % [p = 0.05], respectively), which were associated with a higher readmission rate in a subanalysis of these data. This higher readmission rate associated with low anterior resection could reflect potentially severe complications (e.g., anastomotic leaks), which usually have an asymptomatic course in patients with a diverting stoma, which is routinely performed in an ultra-low anterior resection. It is also worth mentioning that while group A had a higher proportion of rectal prolapse, CPAC, and endometriosis compared to group B, the small sample size makes it impossible to draw any conclusions from these numbers.

Multivariate analysis showed that after adjusting for confounding factors, conversion, postoperative morbidity, and rectal prolapse were independently associated with length of hospital stay. An important issue to consider when analyzing postoperative outcomes of LCR, is the impact of conversion on postoperative results. It is known that conversion is associated with prolonged operative time, increased morbidity, slower recovery, and prolonged hospital stay [21‐23]. Senagore et al. [12], in a series of 181 laparoscopic sigmoidectomies with a conversion rate of 12.1 %, reported a mean hospital stay of 2.9 ± 1.2 days for laparoscopically completed cases versus 6.4 ± 1.4 days for converted cases. They did not, however, report the overall mean hospital stay. Overall, patients with complications often required additional pharmacological treatments or surgical procedures that determine a longer hospital stay. Regarding this issue, postoperative ileus has been identified as the most frequent surgical complication associated with delayed hospital discharge, and laparoscopy has been claimed to reduce postoperative ileus [15]. Interestingly, patients in group A had a lower incidence of postoperative ileus than patients in group B, and there was no association between postoperative ileus and the operation performed. Similar results were reported by Delaney et al. [10]. The small number of rectal prolapse cases makes it difficult to establish why rectal prolapse is associated with earlier hospital discharge. However, we can infer that this is determined by technical aspects of the operation, such as less dissection of the descending colon or the avoidance of unnecessary resections.

Finally, one important argument against fast-track recovery programs is associated with the necessity of home care nursing [24]. However, our study shows that no skilled nursing was required after early discharge following LCR when applying standardized perioperative care programs. Moreover, ERAS programs are often criticized for difficulty in assessing patient compliance [25], and this could be cited as a limitation of our study. Future institutional efforts will be required to oversee this critical aspect of perioperative care.

In conclusion, a two-day hospital stay after LCR is safe and feasible under an ERAS pathway. Patients fulfilling standardized criteria can be safely discharged on the second postoperative day with a low readmission and complication rate. Both conversion to open conventional surgery and postoperative morbidity, however, were associated with prolonged hospital stay.