Benchmarking of aggregated length of stay after open and laparoscopic surgery for cancers of the digestive system

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Abstract

Background

Length of hospital stay (LOS) may serve as a surrogate measure of healthcare quality and resource use, particularly when transfers of care and readmissions are accounted for. This study aimed to benchmark true hospital stay by measuring index, transfer and readmission stays across the range of digestive cancer surgery.

Methods

A cohort study of all patients undergoing resection for cancer of the oesophagus, stomach, liver, pancreas, colon or rectum in 2012–2016 was undertaken. Index LOS, transfer and readmission stays were merged into an ‘aggregated’ length of stay (a‐LOS), and compared between organ sites and between open and minimal‐access approaches.

Results

In total, 24 354 resections were reported (mean age of patients 68·3 years; 51·3 per cent were men). Resections were reported as laparoscopic for 9151 procedures (37·6 per cent), with a further 283 (3·0 per cent) described as converted to open surgery. Use of a‐LOS compared with standard LOS added a median of 5 days for pancreatoduodenectomy, 4 days for major liver resections, 3 days for oesophageal and gastric resections, and 2 days for minor liver, distal pancreatic and rectal resections.

Conclusion

Overall hospital stay across organ sites and procedures is better described by a‐LOS. The study benchmarks the use of total hospital days during the first 30 days in a universal healthcare system.

Related collections

Most cited references 12

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To investigate the feasibility of a 48-hour postoperative stay program after colonic resection. Postoperative hospital stay after colonic resection is usually 6 to 12 days, with a complication rate of 10% to 20%. Limiting factors for early recovery include stress-induced organ dysfunction, paralytic ileus, pain, and fatigue. It has been hypothesized that an accelerated multimodal rehabilitation program with optimal pain relief, stress reduction with regional anesthesia, early enteral nutrition, and early mobilization may enhance recovery and reduce the complication rate. Sixty consecutive patients undergoing elective colonic resection were prospectively studied using a well-defined postoperative care program including continuous thoracic epidural analgesia and enforced early mobilization and enteral nutrition, and a planned 48-hour postoperative hospital stay. Postoperative follow-up was scheduled at 8 and 30 days. Median age was 74 years, with 20 patients in ASA group III-IV. Normal gastrointestinal function (defecation) occurred within 48 hours in 57 patients, and the median hospital stay was 2 days, with 32 patients staying 2 days after surgery. There were no cardiopulmonary complications. The readmission rate was 15%, including two patients with anastomotic dehiscence (one treated conservatively, one with colostomy); other readmissions required only short-term observation. A multimodal rehabilitation program may significantly reduce the postoperative hospital stay in high-risk patients undergoing colonic resection. Such a program may also reduce postoperative ileus and cardiopulmonary complications. These results may have important implications for the care of patients after colonic surgery and in the future assessment of open versus laparoscopic colonic resection.

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Accelerated recovery from surgery has been achieved when patients are managed within a multimodal Enhanced Recovery After Surgery (ERAS) protocol. This study evaluated the benefit of an ERAS programme for patients undergoing liver resection. The ERAS protocol of epidural analgesia, early oral intake and early mobilization was studied prospectively in a consecutive series of 61 patients. Outcomes were compared with those in a consecutive series of 100 patients who underwent liver resection before the start of the study. Endpoints were postoperative length of hospital stay, postoperative resumption of oral intake, readmissions, morbidity and mortality. Fifty-six patients (92 per cent) in the ERAS group tolerated fluids within 4 h of surgery and a normal diet on day 1 after surgery. Median hospital stay, including readmissions, was 6.0 days compared with 8.0 days in the control group (P < 0.001). There were no significant differences in rates of readmission (13 and 10.0 per cent respectively), morbidity (41 and 31.0 per cent) and mortality (0 and 2.0 per cent) between ERAS and control groups. The ERAS fast-track protocol is safe and effective for patients undergoing liver resection. It allows early oral intake, promotes faster postoperative recovery and reduces hospital stay. (c) 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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The combination of laparoscopic colorectal surgery together with an enhanced recovery program has resulted in short hospital stays. The purpose of this study was to assess the acceptability and safety of a 23-hour-stay protocol developed for patients undergoing laparoscopic colectomy. Patients undergoing elective laparoscopic colorectal resection who met the inclusion criteria were invited to participate in the study. A specific preoperative, anesthetic, and postoperative protocol was used. Patients were discharged 23 hours after the start of surgery. Follow-up was by telephone contact on the evening of the day of discharge with outpatient follow-up at Day 3. Ten patients were included in the study. All patients were discharged within 23 hours from the commencement of surgery. There were no complications and no readmissions to the hospital. All patients were satisfied with the service; all ten would request to follow the same pathway again if required, and all would recommend it to other patients. A 23-hour-stay laparoscopic colectomy is possible with modification of the enhanced recovery program. Patients find it acceptable and it seems to be safe.

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All references

Author and article information

Contributors

K. Lassen:

ORCID: http://orcid.org/0000-0003-0039-6554

krlass@ous-hf.no

Journal

Journal ID (nlm-ta): BJS Open

Journal ID (iso-abbrev): BJS Open

Journal ID (doi): 10.1002/(ISSN)2474-9842

Journal ID (publisher-id): BJS5

Title: BJS Open

Publisher: John Wiley & Sons, Ltd (Chichester, UK )

ISSN (Electronic): 2474-9842

Publication date (Electronic): 23 April 2018

Publication date Collection: August 2018

Volume: 2

Issue: 4 ( doiID: 10.1002/bjs5.2018.2.issue-4 )

Pages: 246-253

Affiliations

[ ¹ ] Department of Hepato‐Pancreato‐Biliary Surgery Oslo University Hospital Oslo Norway

[ ² ] Department of Gastrointestinal Surgery University Hospital of North Norway Tromsø Norway

[ ³ ] Institute of Clinical Medicine University of Tromsø Tromsø Norway

[ ⁴ ] Centre for Clinical Documentation and Evaluation Northern Norway Regional Health Authority Tromsø Norway

[ ⁵ ] Department of Clinical Medicine University of Bergen Bergen Norway

[ ⁶ ] Department of Gastrointestinal Surgery Stavanger University Hospital Stavanger Norway

[ ⁷ ] Department of Clinical Surgery Royal Infirmary of Edinburgh, and University of Edinburgh Edinburgh UK

Author notes

[*] [* ] Correspondence to: Professor K. Lassen, Department of Hepato‐Pancreato‐Biliary Surgery, Oslo University Hospital at Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway (e‐mail: krlass@ 123456ous-hf.no ;

@xtofero)

Author information

K. Lassen http://orcid.org/0000-0003-0039-6554

Article

Publisher ID: BJS567

DOI: 10.1002/bjs5.67

PMC ID: 6069352

PubMed ID: 30079394

SO-VID: a11efa5d-d0b1-420b-884e-28649e54fb02

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

History

Date received : 18 February 2018

Date accepted : 07 March 2018

Page count

Figures: 3, Tables: 1, Pages: 8, Words: 3707

Custom metadata

source-schema-version-number 2.0

component-id bjs567

cover-date August 2018

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:version=5.4.4 mode:remove_FC converted:01.08.2018