A combination of 4 clinical criteria and C-reactive protein (CRP) levels may allow patients to be discharged early and safely following laparoscopic colorectal surgery, according to a study in JAMA Surgery.
The prospective, noninterventional study was conducted in a colorectal surgery department in Lyon, France. Investigators assessed the feasibility and safety of an early discharge within 3 days after an enhanced recovery program following laparoscopic colorectal surgery, provided patients met the following 5 criteria — a CRP level <150 mg/dL, an absence of fever during the entire hospital stay (temperature <38°C), a return of bowel function (flatus with or without stool), adequate pain control with oral analgesics (pain <5 on a 10-point visual analog scale), and tolerance of a solid diet.
Adult patients who had laparoscopic colorectal surgery between February 2012 and July 2017 were included. Postoperative visits occurred 15 and 30 days after discharge. Diagnostic performance of the 5 criteria in ruling out an anastomotic leak was the primary outcome.
A total of 287 patients (median age, 58 years) had laparoscopic colorectal surgery, and their median length of stay was 4 (IQR, 2) days. Among this group, 128 patients (median age, 59 years; IQR 49-66 years; 54% men) fulfilled the 5 criteria, 125 did not, and 34 had missing data.
Of the 128 patients who fulfilled the 5 criteria, 76 (59.4%) were discharged by postoperative day 3, and the other 52 (40.6%) were discharged at later dates.
The negative predictive value (NPV) of fulfilling the 5 criteria in ruling out anastomotic leaks was 98.4% (95% CI, 94.5-99.8), and the positive predictive value was 78.9% (95% CI, 70.6-85.7). The false-negative rate of the 5 criteria for anastomotic leaks was 13.3% (95% CI, 0-40.5). These data were based on 253 patients.
The NPV for ruling out an anastomotic leak was at least 96.9% for CRP alone (95% CI, 93.3-98.8) and 98.4% (95% CI, 95.3-99.7) for the 4 clinical criteria.
The false-negative rate increased from 13.3% (95% CI, 0-40.5) for the 5 criteria, to 20% (95% CI, 4.3-48.1) for the 4 criteria, to 40% (95% CI, 16.3-67.7) for the CRP levels alone.
Of the 128 patients who fulfilled the 5 criteria, 2 developed an anastomotic leak compared with 13 patients who had an anastomotic leak among those who did not fulfill the criteria (hazard ratio, 0.15; 95% CI, 0.03-0.69; P =.01, according to multivariate Cox analysis).
Among several study limitations, data on 11.8% of patient CRP levels were missing. Additionally, the cohort was heterogeneous, and the criteria may be applicable in multiple settings because of this heterogeneity.
“Our study shows that a patient fulfilling our 5 criteria on [postoperative days] 2 or 3 has a low probability of developing an [anastomotic leak],” stated the researchers. “This potentially allows for an early safe discharge,” they concluded.
Disclosure: Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Tavernier C, Flaris AN, Passot G, Glehen O, Kepenekian V, Cotte E. Assessing criteria for a safe early discharge after laparoscopic colorectal surgery. JAMA Surg. Published online November 3, 2021. doi: 10.1001/jamasurg.2021.5551