Early Discharge after Laparoscopic Colorectal Surgery Accelerates Recovery

By Conor Delaney, MD, PhD

Case vignette:

A 62-year-old man presented to his physician with rectal bleeding and weight loss. A colonoscopy revealed upper rectal cancer, and he was referred to Cleveland Clinic for treatment. After we obtained an MRI and CT, his case was presented at Tumor Board. He was determined to be a suitable candidate for immediate surgery and underwent a laparoscopic low anterior resection.

After surgery, the patient was managed with an enhanced recovery “fast-track” protocol. He was given analgesics and liquids to drink in the recovery room. That evening, he ambulated around the hospital floor. The following morning, his IV was removed and he was given oral analgesics and breakfast. On oral acetaminophen and ibuprofen, his pain score was 3/10. He had a light lunch. By late afternoon, he had recovered gastrointestinal function and was feeling well enough to be discharged home.

In a follow-up call the next day, he reported tolerating the 2 ½-hour drive home comfortably and was feeling fine. A few days after surgery, he was functioning quite normally. At his two-week checkup to discuss further management of his cancer, he reported being pain-free and back to normal activities.

Securing the safety of early discharge

In 2005, the average length of stay following open colectomy was 10.6 days.

The advent of minimally invasive colorectal surgical techniques enabled us to substantially reduce that number. Today, we safely discharge 50 percent of patients within 48 hours, because they feel so well they wish to leave hospital.

Successful early discharge mandates the use of a set of standardized discharge criteria we call an enhanced recovery pathway, or “fast-track” protocol. Despite initial concerns that early discharge might be disadvantageous, studies showed that a shorter primary length of stay following colectomy resulted in a lower likelihood of readmission. In our experience, patients discharged within 72 hours of surgery are significantly less likely to have a complication than those who remain hospitalized for more than 72 hours and are less likely to be readmitted.

To be clear, early discharge itself does not prevent complications; rather, patients who are well enough to eat, drink and ambulate early after surgery are recovering without complications. Those who are not doing as well are at higher risk for complications and require observation for a few more days.

Factors that delay discharge after laparoscopic colectomy include pain, nausea and vomiting, ileus, fatigue, the need for drains and stress-induced organ dysfunction. A multimodal postoperative “fast-track” discharge protocol can be used to regulate the introduction of diet, analgesia and ambulation. When combined with laparoscopy, this protocol allows patients to undergo major intestinal surgery and recover quickly enough to go home within as little as 48 hours after surgery.

Elements of an enhanced recovery pathway

After colorectal surgery, patients can be discharged when their pain is well controlled, when they are eating and drinking adequately, and when their vital signs and laboratory tests are normal and they have recovered gastrointestinal function. Enhanced recovery pathways are designed to achieve these goals as quickly as possible.

In 2000, we initiated the use of an enhanced recovery pathway that included the regulation of postoperative fluids, early ambulation, early feeding and gastric stimulation, postoperative pain control and pharmacologic treatment of ileus. Multiple studies have since demonstrated the feasibility, safety and success of such protocols. Today, many institutions have developed similar protocols. All incorporate accelerated mobilization and early postoperative feeding, but other elements vary. We believe critical elements include:

• Minimal postoperative intravenous fluids to avoid cardiopulmonary complications
• Transition from intravenous to oral analgesics on postoperative day 1
• Use of multimodal oral analgesics (Tylenol, Advil, neurontin, and nerve blocks) to reduce opioid use and associated nausea and vomiting
• Elimination of nasogastric tubes and early transition to carbohydrate-rich liquids and foods
• Prevention of ileus with appropriate pharmacological therapy (potentially with a new mu-opioid antagonist) and gum chewing
• Early ambulation after surgery
• Venous thromboprophylaxis
• Use of prophylactic perioperative antibiotics
• Treatment of postoperative adrenal insufficiency

The take-home message

The elements of a comprehensive fast-track protocol are too lengthy to explain in a short article. If you would like more information, I suggest you read the chapter we wrote on “Postoperative Management,” in The ASCRS Textbook of Colon and Rectal Surgery: Second Edition. The point I want to emphasize here is that the combination of laparoscopic colectomy with an enhanced recovery pathway will allow the majority of your patients to be discharged sooner and return to normal function more quickly. This can be highly beneficial for all patients, but especially valuable for frail patients, for whom a lengthy hospital stay may lead to extended recovery time.