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Feasibility and safety of ambulatory surgery as the next management pardigm in colorectal resection surgery
Ravi P. Kiran, Koby Herman, Dilara Khoshknabi, Athanasios Angistriotis, James M. Church
Colorectal Surgery, Columbia University Medical Center, New York, New York, United States

Objectives: Current clinical dogma favors universal inpatient admission after colorectal resection particularly in the presence of an anastomosis. We evaluate the feasibility and safety of ambulatory surgery in carefully selected patients undergoing colorectal resection/anastomosis.
Methods: Between October 2020-October 2021, all patients undergoing colorectal resection/anastomosis meeting specific criteria (no major comorbidity (ASA<4), not on therapeutic anticoagulation, compliant patient/family) were counseled preoperatively for ambulatory surgery (discharge <24 hours post surgery). Complicated surgery(ileoanal pouch, enterocutaneous fistula repair, reoperative pelvic surgery, multiple resections) and/or ostomy creation(loop/end ileostomy, Hartmann's, abdominoperineal resection) were exclusions. Discharge was at 6-8 hours postoperatively if all predetermined factors (no ostomy teaching needed, ambulating comfortably, tolerating diet, stable vitals and blood-work) were met and patients were willing, or postponed to the next day at patient request. All discharged patients received phone checks the next day with the option also given for voluntary readmission if inpatient care preferred by patient. Patients discharged <24 hours postop (AmbC) were compared to those staying on as inpatients (InpC) and also to a comparable historical (October 2019-October 2020) group when ambulatory surgery was not on offer (HistC).
Results: Of 184 abdominal colorectal surgery patients, 97 had complicated colorectal resection and/or ostomy. Of the remaining 87, 29 (33.3%) were discharged <24 hours postoperatively (7 (24%) patients at 8 hours). Of the 29 AmbC patients, 4 were readmitted <30 days (ileus:1, rectal bleeding:2, nausea/vomiting:1), 1 readmission was on first post-discharge day, none were voluntary post phone-check. AmbC and InpC (n=58) had similar age, gender, race, body mass index (BMI) and comorbidity (table). InpC had greater estimated blood loss (109 vs 34 ml, p<0.001) while length of stay (LOS) was expectedly significantly longer (109 vs 17 hours, p<0.001). There was no mortality in either group. AmbC and InpC had similar readmission, reoperation, anastomotic leak, ileus and surgical site infection (SSI). Mean LOS for HistC was 83 hours. AmbC and HistC had similar age, gender, race, BMI and ASA class. Complications including readmission, reoperation, anastomotic leak, ileus and SSI were also similar for AmbC and HistC.
Conclusions: With careful preoperative education, perioperative management and postoperative follow-up, ambulatory surgery is feasible in up to a third of patients undergoing colorectal resection/anastomosis and can be performed with comparable safety to the time-honored practice of routine inpatient hospitalization. Further refining inclusion/exclusion criteria and postoperative outpatient follow-up will allow a paradigm shift in how such patients are managed, which has huge implications for patients, care-givers and healthcare systems.



 AmbC (N=29)InpC (N=58)P value*HistC (N=88)P value**
Age, years, mean (SD)55.2 (14.7)58.3 (18.4)0.360.2 (18.1)0.1
Female Sex, n (%)13 (44.8)34 (58.6)0.247 (53.4)0.4
Race/Ethnicity, n (%)
White
Non-White†
-
18 (62.1)
11 (37.9)
-
42 (72.4)
16 (27.6)
0.5
-
-
64 (72.7)
24 (27.3)
0.3
-
ASA Class, n (%)
1/2
3
-
20 (69)
9 (31)
-
31 (53.4)
27 (46.6)
0.2
-
-
47 (53.4)
41 (46.6)
0.1
-
BMI, kg/m^2, mean (SD)27.0 (6.1)26.1 (6)0.627.6 (5.8)0.4
Medical comorbidities, n (%)
HTN
DM
Cardiac comorbidity†
COPD
CKD
Chronic steroid use
-
5 (17.2)
2 (6.9)
0 (0)
0 (0)
1 (3.4)
0 (0)
-
19 (32.8)
8 (13.8)
6 (10.3)
6 (10.3)
3 (5.2)
2 (3.4)
-
0.1
0.5
0.2
0.5
1.0
0.5
-
40 (45.5)
17 (19.3)
2 (2.3)
4 (4.5)
1 (1.1)
2 (2.3)
-
0.007
0.2
1.0
0.6
0.4
1.0
Non-smoker, n (%)27 (93.1)56 (96.6)0.687 (98.9)0.2
Primary Diagnosis, n (%)
Malignancy/Adenoma
Diverticular Disease
IBD
Other
-
15 (52)
5 (17)
5 (17)
4 (14)
-
25 (43.1)
17 (29.3)
10 (17.2)
6 (10.4)
 -
37 (42)
20 (23)
14 (16)
17 (19)
 
Operation type, n (%)
Laparoscopic
- Ileocolic Resection
- Right Colectomy
- Transverse Colectomy
- Left Colectomy
- Sigmoid Colectomy
- Low Anterior Resection
- Subtotal Colectomy
Open
- Ileocolic Resection
- Right Colectomy
- Transverse Colectomy
- Sigmoid Colectomy
- Low Anterior Resection
-
-
4 (11)
8 (30)
0 (0)
0 (0)
12 (44)
4 (11)
1 (4)
-
-
-
-
-
-
-
-
9 (16)
8 (14)
3 (5)
4 (7)
21 (36)
6 (10)
2 (3)
-
1 (2)
1 (2)
1 (2)
2 (3)
0 (0)
 -
-
14 (16)
25 (28)
1 (1)
5 (5)
22 (25)
12 (14)
4 (4)
-
0 (0)
0 (0)
1 (1)
3 (3)
3 (3)
 
Length of Stay, hours, mean (SD)
0-8 hours, n (%)
9-24 hours, n (%)
17.19 (7.38)
7 (24)
22 (76)
109 (102.9)
-
-
<0.001
-
-
83.17 (67.3)
-
-
<0.001
-
-
EBL, mL, mean (SD)34.14 (75.5)109 (134.7)<0.001122.5 (188)<0.001
30-day Post-operative complications, n (%)
Any complication
Readmission
Post-discharge day 0-1, n (%)
Post-discharge day 2-5, n (%)
Reoperation
Anastomotic Leak
Ileus
SSI (any)
Transfusion
-
4 (13.8)
4 (13.8)
1 (25)
3 (75)
0 (0)
0 (0)
1 (3.4)
0 (0)
0 (0)
-
17 (29.3)
4 (6.9)
1 (25)
3 (75)
2 (3.4)
3 (5.2)
4 (6.9)
2 (3.4)
9 (15.5)
-
0.1
0.4
-
-
0.5
0.5
0.7
0.5
0.03
-
20 (22.7)
7 (8)
-
-
0 (0)
1 (1.1)
5 (5.7)
4 (4.5)
9 (10.2)
-
0.3
0.5
-
-
-
1.0
1.0
0.6
0.1


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