5 Criteria Could Enable Safe Early Discharge After Laparoscopic Colorectal Surgery

By Marilynn Larkin

November 15, 2021

NEW YORK (Reuters Health) - Patients fulfilling five common criteria two to three days after laparoscopic colorectal surgery have a low risk of developing anastomotic leaks and may be discharged as early as postoperative day (POD) 2 researchers suggest.

The criteria are: 1) C-reactive protein (CRP) <150mg/dL; 2) return of bowel function; 3) solid diet; 4) pain <5/10 on a visual analogue scale; and 5) afebrile during entire stay.

"Our criteria are easy to apply to everyday practice and are intuitively appealing, as most surgeons would argue that a patient that fulfills them is probably ready for discharge anyway;" Dr. Eddy Cotte of Lyon Sud University Hospital in France and Alexandros Flaris of Tulane University School of Medicine in New Orleans told Reuters Health in a joint email.

"Our findings are most probably not practice-changing, as many clinicians may already be using them," they said. "However, this study bridges the gap between common sense and experimental validation. Even though our discharge criteria may be already in use, there has been no formal study demonstrating that they can indeed be used."

"Most studies attempting to determine how to rule out anastomotic leaks after colorectal surgery focus on the negative predictive value of CRP," they added. "We chose the false-negative rate, which does not depend on prevalence and which shows that our five criteria are a reasonable test to evaluate patient dischargeability."

As reported in JAMA Surgery, the team analyzed data on 287 patients (median age, 58; 49% men) who underwent laparoscopic surgery at Lyon Sud University Hospital and were followed for 30 days.

Seventeen anastomotic leaks occurred, of which two were on day 1 and were excluded. One hundred and twenty-eight patients fulfilled all five criteria, and 125 did not, including 34 for whom data were missing.

Two leaks occurred in patients who had fulfilled all criteria versus 13 leaks in those who did not (hazard ratio, 0.15).

Seventy-six of 128 patients (59.4%) were discharged successfully by POD 3.

The negative predictive value in ruling out an anastomotic leak was at least 96.9% for CRP alone; 98.4% for the four clinical criteria; and 98.4% for all five criteria.

False-negative rates were 40% for CRP level alone; 20% for the other four criteria, and 13.3% for all five criteria.

No deaths occurred.

The authors conclude, "These 5 criteria have a high negative predictive value and the lowest false-negative rate, indicating they have the potential to allow for safe early discharge after laparoscopic colorectal surgery."

Drs. Cotte and Flaris add, "Our take-home message is as simple as our discharge criteria: if a patient is doing well on postoperative days 2 or 3, then he or she can probably go home. We hope that with correct application of our study findings, our colleagues will be able to decrease their patients' length of stay, healthcare costs and resource utilization, amidst a pandemic where every hospital bed counts."

Dr. Rahul Narang, a colorectal surgeon at NYU Langone's Perlmutter Cancer Center in New York City, commented on the study in an email to Reuters Health. "Current procedure for safe postoperative discharge varies among individual surgeons," he said. "Multiple factors such as vital signs, evaluation of laboratory tests including leukocytosis, return of bowel function and a clinical exam can be used to determine the number days in the hospital after surgery."

Further studies are needed," he said, "to understand how patients' CRP response varies depending on the surgical approach (laparoscopic vs. open vs. robotic) and what CRP lab values we should consider high enough to determine that a patient has an anastomotic leak."

SOURCE: https://bit.ly/3c4UIPd JAMA Surgery, online November 3, 2021.