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THE UNWANTED SIDE-EFFECT OF THE ERAS PROTOCOL IN COLON CANCER SURGERY
Lieve G. Leijssen*1,2, Anne M. Dinaux1,2, Hiroko Kunitake1,2, Liliana G. Bordeianou1,2, David L. Berger1,2
1General and Gastrointestinal Surgery, Massachusetts General Hospital, Boston, MA; 2Harvard Medical School, Boston, MA
Introduction
Enhanced Recovery After Surgery (ERAS) programs have shown an improvement in length of stay and reduction in morbidity after laparoscopic colorectal surgery. However, we still haven’t conquered the problem of readmission in the era of shorter length of hospital stay. The aim of this study is to assess the impact of laparoscopic resections in colon cancer surgery on readmission rates, as well as reasons for readmission.
Methods
All patients who underwent either an open (OS) or laparoscopic (LS) procedure for colon cancer at our tertiary center from 2004 to 2014 were included in an institutional review board-approved database (n=1271). We analyzed all patients who were readmitted to the hospital within 35 days of discharge (n=98). We reviewed patient demographics, perioperative variables, postoperative complications and readmission rates. A multivariable analysis controlling for significant factors was performed to evaluate factors associated with readmission.
Results
Of all patients, 363 (28.6%) underwent laparoscopic surgery for colon cancer. Age (median 64.5 vs. 69.0; P <0.001), and a higher ASA score (mean 2.2 vs. 2.5; P <0.001) were associated with open surgery. Laparoscopic operations were associated with a shorter length of stay (median 3 vs. 6 days; P<0.01), lower readmission rates (5.0% vs. 8.0%; P<0.05), less need for blood transfusion (P<0.001), less peri-operative and admission complications, and mortality rates (P<0.05). The two most common reasons for readmission in patients who underwent a laparoscopic procedure were ileus (31.3%) and wound infection (21.4%). During initial admission an ileus occurred significantly more often after open surgery (P <0.001). However, patients who were readmitted with an ileus were significantly more often laparoscopically treated (44.4% vs 7.5%; P<0.001). Adjusting for baseline characteristics and gastrointestinal comorbidities, patients who underwent a laparoscopic procedure yield still larger odds ratios for readmission with ileus (OR: 8.6, 95% CI 2.4-30.6; P<0.001).
Conclusion
Laparoscopic treatment for colon cancer is associated with a shorter length of stay without an increase in readmission rates, and a lower risk of complications during admission.
However, our study shows more postoperative ileus and the necessity to be readmitted after laparoscopic procedures. We need to ensure that we strive for improvement of perioperative care and recovery and that reduction of length of stay is not the sole goal of an ERAS program.
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