Ambulatory colectomy safe, feasible for 'carefully selected' patients

Last Updated: 2018-05-28

By Reuters Staff

NEW YORK (Reuters Health) - Many patients who require elective colectomy may be candidates for ambulatory surgery, new research shows.

"In our experience, 30% of patients scheduled for elective colectomy can be managed in an ambulatory setting," Dr. Benoit Gignoux of the Clinique de la Sauvegarde in Lyon, France, and colleagues conclude in the Annals of Surgery, online May 1.

Dr. Gignoux performed the first ambulatory left colectomy, in a 66-year-old man with sigmoid carcinoma, in 2013. He and his colleagues had previously been able to reduce hospital stay after colectomy by implementing enhanced recovery guidelines that promote an early return to normal diet and activity, which also reduced morbidity and mortality.

"When we decided to pioneer this project involving a series of consecutive ambulatory colectomies for selected patients, the entire team for the patient (surgeons, anesthetists, nurses, dietitians and physiotherapists), the institutional support system, the primary care physicians, and the patients themselves were completely ready," the authors note.

They report on 157 consecutive ambulatory colectomy patients treated at the Clinique de la Sauvegarde and L'Hopital Prive de l'Estuaire in Le Havre from 2013 to 2016, and 357 additional patients who had colectomies in a conventional hospital setting.

Inclusion criteria included American Society of Anesthesiologists (ASA) grade of I, II, or III; requirement for elective laparoscopic colectomy, full understanding of the procedure and the enhanced recovery program; favorable social conditions; and wanted ambulatory management. Exclusion criteria were prior midline laparotomy, large T4 tumors, multiple colonic lesions, low rectal resection, history of perforated sigmoid diverticulitis, emergency surgery, planned stoma, severe denutrition, insulin-dependent diabetes, nervous depression, curative anticoagulant treatment. One-third of the ambulatory cases were cancer-related. In nearly all of the others, surgery was indicated for sigmoid diverticulitis.

Median procedure time was 95 minutes, while median length of hospital stay was 10 hours.

Eleven patients (7%) had to spend the night in the hospital after the surgery, due to "operative difficulties, medical reasons, and social reasons," the authors note. All of these patients had "uneventful" outcomes and spent a median 3.1 days in the hospital.

Thirty patients required an unscheduled consultation (20.5%), nine required readmission (6.1%), and six of these patients required additional surgery. Thirty-day morbidity rate was 24.8% overall, and mortality rate was 0%.

"Mortality did not occur in this series, probably due to the strict selection of patients and early diagnosis of the serious complications due to rigorous surveillance," they authors write.

"Very short hospital stays after colectomy require establishment of a specific at-home monitoring system to avoid any delay in the diagnosis and management of life-threatening complications," they add.

Dr. Gignoux was not available for an interview by press time.

SOURCE: https://bit.ly/2L2L93A

Ann Surg 2018.