Criteria May Establish Patient Eligibility for Early Discharge Following Laparoscopic Colorectal Surgery

Male surgeons performing laparoscopic surgery. Doctors are monitoring patient in operating room. They are in hospital.
Investigators assessed the safety and feasibility of an early discharge following laparoscopic colorectal surgery based on 4 clinical criteria and C-reactive protein levels.

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.

Reference

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