FAST-TRACK COLECTOMY Mehran Anvari, MBBS, PhD, FRCSC, FACS, performs laparoscopic colectomy on a patient at the Centre for Surgical Invention & Innovation in Canada.

Colectomy may not be a procedure regularly handled on an outpatient basis, but laparoscopic technology and changes in post-op care are revolutionizing the average length of stay for patients — making a 23-hour discharge after colectomy possible.

New technology and a better understanding of how to care for patients after surgery have decreased the average amount of time most patients stay in the hospital from 11 days to about 8 days, but there are some physicians advancing the procedure further, with patients leaving in just 23 hours.

Experts say that about 25% of patients undergoing laparoscopic colectomies are able to leave within the same day. How is it possible? Anthony J. Senagore, MD, MS, MBA, clinical professor of surgery at Case Western Reserve University and University Hospitals of Cleveland in Ohio, gives credit to laparoscopic surgery, along with changes in how to manage pain and an early introduction of a diet and ambulation. "It all translates into an earlier transition to home," he says.

Intraoperative techniques
Laparoscopic surgery has been around for a while but it's still struggling to catch on for colectomy procedures. According to Mehran Anvari, MBBS, PhD, FRCSC, FACS, professor of surgery and chair of minimally invasive surgery and surgical innovation at McMaster University in Hamilton, Ontario, only 40% of colectomy procedures in Canada are done using laparoscopy over the traditional open technique, despite its many benefits. The smaller incision, experts say, reduces the unwanted effects of open surgery that traditionally keep patients in the hospital longer, like pain and risk of infection. "With laparoscopy, patients' pain is less and their recovery is so much quicker," says Dr. Anvari.

Laparoscopic surgery isn't the only thing contributing to faster recoveries. Advancements in anesthesia have meant that patients can wake up more quickly and experience less post-op pain, making discharge after 23 hours possible.

INSIDE LOOK Laparoscopic surgery has made the 23-hour discharge for colectomy procedures possible.

Conor P. Delaney, MD, PhD, chief of colorectal surgery and interim chair of surgery at University Hospitals Case Medical Center in Cleveland, Ohio, says his hospital uses transversus abdominis plane blocks (TAP blocks) to reduce patient pain and time spent in the hospital after a colectomy. These long-lasting blocks are designed to anesthetize the nerves supplying the anterior abdominal wall. Studies have shown that TAP blocks reduce the amount of pain patients experience post-op and the amount of opioids they need after surgery. Dr. Senagore says that by using nerve blocks for colectomies, patients can be switched to ibuprofen or acetaminophen within a day of surgery, making the transition home easier.

While nasogastric tubes and other drains are used during traditional colectomy procedures, experts say it's best to avoid them, as they aren't necessary and in some cases can even lengthen a patient's recovery. "Nasogastric tubes are not proven to help reduce vomiting after surgery, but about 25% of surgeons still use them," says Dr. Delaney.

Post-operative care
One of the advances making 23-hour-discharge colectomy possible is the introduction of enhanced recovery pathways, a multimodal perioperative care approach that focuses on improving a patient's recovery after surgery, says Dr. Delaney. These pathways look at specific ways to care for a patient before, during and after colorectal surgery, and have been shown to decrease the amount of time a patient must spend in a hospital.

Traditionally, says Dr. Delaney, patients were expected to stay in the hospital for 10 days, were confined to bed rest for 2 of them, and could not eat or drink for 5 days after surgery. The enhanced recovery pathway instead asks that patients eat and drink as soon as they're comfortable and walk within a day of surgery. "This is really turning things on its head," he says.

While Dr. Delaney uses a specific enhanced recovery pathway for his hospital, the general idea of quick ambulation and early introduction of a diet is something that has done away with nearly 2-week long hospital stays following colectomy procedures. Put simply, Dr. Anvari says, "All you're waiting for is for patients to be comfortable and for them to be able to drink something."

The experts say patients should be encouraged to ambulate and drink something on the same day of surgery, and should be given an easy-to-digest breakfast the next morning. If they feel comfortable after that, patients can then move onto a basic diet. Patients should also be transitioned from IV pain medication to oral pills as soon as they can tolerate them. It's also important, the experts say, for the patient to feel ready to go home. "We won't push patients out if they don't feel comfortable," says Dr. Anvari.

The experts also agree that using these new standards and reducing length of stay for patients doesn't negatively impact the patient's care. In fact, studies have suggested that newer standards reduce post-op complications. Dr. Delaney says that when compared to patients who stay traditional lengths of time after colectomies, these fast-track discharge patients "do just as well," and those who leave within that first day often have a lower readmission rate than others who stay longer than 23 hours. "If patients did worse after surgery, that would be a big problem," says Dr. Delaney.

23-HOUR DISCHARGE Conor P. Delaney, MD, PhD, at the University Hospitals Case Medical Center, reduces the amount of time patients spend at the hospital through enhanced recovery pathways.

Patient characteristics
While the new standards in colectomy — which the surgeons say are performed on nearly all patients, regardless of how long they're predicted to stay in the hospital — enable a same-day procedure to be done, it's really the patients that make the difference when it comes to how long they stay at the hospital and if they can leave within a day. "It's not going to be the 93-year-old who has a bad heart and no one at home," says Dr. Delaney. "You have to have the right patients."

Typically, experts say these factors determine how quickly a patient is discharged following colectomy:

• Home support. This is one of the most crucial factors for determining if a patient is eligible for a same-day discharge. Patients can't go home early if there's no one there to monitor and take care of them.
• Comorbidities. Patients who can leave within 23 hours tend to be healthy and have no other major co-morbidities, the surgeons say. Someone with heart disease or diabetes will likely have a longer recovery.
• Cause for surgery. A patient who is getting surgery because he has a small polyp but is otherwise stable will be released much sooner than someone who is having her colon removed because of a bad case of Crohn's Disease or diverticulitis, says Dr. Anvari.
• Age. Age isn't a limiting factor of whether someone is a candidate for same-day colectomy, but younger, healthier patients generally fare better.

While Dr. Delaney doesn't think that "23-hour discharge will become the standard," others believe that as more surgeons are trained on these techniques, these new standards will likely take hold.

"There's no disadvantage to doing this," says Dr. Senagore. "There's no 'too early' to go home."