Alvimopan Significantly Reduces Length of Stay and Costs Following Colorectal Resection and Ostomy Reversal Even Within an Enhanced Recovery Protocol.

BACKGROUND: Alvimopan accelerates GI recovery after colorectal resection. Data on real-world cost-effectiveness have been mixed. OBJECTIVE: This study aimed to evaluate if adding alvimopan to an enhanced recovery pathway reduces length of stay. DESIGN: Patients undergoing colorectal resection or ostomy reversal for the year before and after the introduction of alvimopan were evaluated. SETTING: This study was conducted at a single academic medical center. PATIENTS: Patients undergoing elective colorectal resection (488) or ostomy reversal (148) were included. MAIN OUTCOME MEASURES: The primary outcomes measured were length of stay and prolonged length of stay defined as >75th percentile for each procedure. RESULTS: Two hundred eighty-six patients (45%) received alvimopan. Alvimopan and no-alvimopan groups had similar demographics, comorbidities, operative indication, and case mix. In the alvimopan group, more of the colorectal resections were laparoscopic (87% vs 79%, p = 0.015). Length of stay was reduced with alvimopan (6.2 vs 4.9 days, p = 0.003), and this effect persisted when controlling for procedure type, approach, and ASA class (decreased length of stay by 1.0 day, p = 0.014). The alvimopan group had lower risk of prolonged length of stay (14.7% vs 23.1%, p = 0.007) and ileus (10.8% vs 16.2%, p = 0.05). On multivariable analysis, no alvimopan use (OR, 1.8; 95% CI, 1.2-2.7), ASA ≥3 (OR, 2.0; 95% CI, 1.3-3.1), and history of cardiac surgery (OR, 2.8; 95% CI, 1.2-6.5) were significant predictors of prolonged length of stay. Alvimopan use was associated with a lower risk of infectious complications other than surgical site infection (2.8% vs 6.7%, p = 0.025), and did not increase risk of any adverse outcomes. The addition of alvimopan to the protocol resulted in cost savings of $708.39 per patient. LIMITATIONS: Data collected from a single center limit external validity. CONCLUSIONS: The introduction of alvimopan to a postoperative protocol following elective colorectal resection or ostomy reversal significantly reduces length of stay and is associated with cost savings even within an enhanced recovery protocol. See Video Abstract at http://links.lww.com/DCR/A911.

Readmissions after colorectal surgery: not all are equal.

PURPOSE: This study aims to assess factors associated with preventable readmissions after colorectal resection. METHODS: All readmissions following colorectal resection from May 2013 to May 2016 at an academic medical center were reviewed. Readmissions that could be prevented were identified. Factors associated with preventable readmission were assessed using logistic regression. RESULTS: Of 686 patients discharged during the study period, there were 75 patients (11%) with unplanned readmission. Twenty-nine readmissions (39%) were preventable-these readmissions were due to dehydration or acute kidney injury, pain, ostomy complications, and gastrointestinal bleeding. On regression analysis, the strongest preoperative risk factors associated with preventable readmission were urgent or emergent operation (OR 4.0, 95% CI 1.6-9.9), recent myocardial infarction (OR 2.9, 95% CI 1.0-9.0), total or subtotal colectomy (OR 2.8, 95% CI 1.1-7.3), and American Society of Anesthesiologist score ≥ 3 (OR 2.2, 95% CI 1.0-4.7). Intraoperative risk factors associated with preventable readmission included intraoperative stapler complication (OR 24.2, 95% CI 1.5-397). Postoperative risk factors associated with preventable readmission included postoperative arrhythmia (OR 5.6, 95% CI 2.0-16.1), and postoperative anemia (OR 2.6, 95% CI 1.2-5.7). On multivariable analysis while controlling for procedure type, urgent or emergent operation (OR 2.9, 95% CI 1.1-8.2), intraoperative stapler complication (OR 37.5, 95% CI 2.3-627.8), and postoperative arrhythmia (OR 4, 95% CI 1.3-12.8) remained statistically significant. CONCLUSION: Approximately 40% of readmissions following colorectal surgery are potentially preventable. Since specific patients and factors that are associated with preventable readmission can be identified, resources should be targeted to factors associated with preventable readmissions.

ACS-NSQIP risk calculator predicts cohort but not individual risk of complication following colorectal resection.

OBJECTIVE: Compare the ACS-NSQIP risk calculator with institutional risk for colorectal surgery. METHODS: Actual and predicted outcomes were compared for both cohort and individuals. RESULTS: For the cohort, the risk calculator was accurate for 7/8 outcomes; there were more serious complications than predicted (19.4 vs 14.7%, p < 0.05). Risk calculator Brier scores and null Brier scores were comparable. PATIENTS: with better outcomes than predicted were current smokers (OR 4.3 95% CI 1.2-15.4), ASA ≥ 3 (OR 10.4, 95% CI 2.8-39.2), underwent total/subtotal colectomy (OR 3.5, 95% CI 1.1-12.2) or operated by Surgeon 2 (OR 2.9, 95% CI 1.4-11.6). Patients with serious complications who had low predicted risk had low ASA (OR 10.5, 95% CI 1.3-82.6), and underwent operation by Surgeon 2 (OR 11.8, 95% CI 2.5, 55.2). LIMITATIONS: Single center study, sample size may bias subgroup analyses. CONCLUSIONS: The ACS NSQIP calculator did not predict outcome better than sample risk.

Effect of Inclusion of Oral Antibiotics with Mechanical Bowel Preparation on the Risk of Clostridium Difficile Infection After Colectomy.

BACKGROUND/PURPOSE: While the use of oral antibiotic (OA) for bowel preparation is gaining popularity, it is unknown whether it increases the risk of Clostridium difficile infection (CDI). This study aimed to evaluate the impact of OA on the development of CDI after colectomy. METHODS: Patients who underwent colectomy from the ACS-NSQIP data (2015 and 2016) were included. Patients who received OA as bowel preparation were compared to those who did not with respect to demographics, comorbidities, primary diagnosis, procedure type and approach, and 30-day postoperative complications. Multivariable analysis was performed to characterize the association between OA and CD infection after colectomy. A sub-group analysis was also conducted for patients who did not develop any postoperative infectious complication. RESULTS: Of 36,374 included patients, 18,177 (50%) received OA and 527 (1.4%) developed CDI for the whole cohort. OA group had more younger, functionally independent and obese patients with lower American Society of Anesthesiologists and wound class. Smoking, diabetes, hypertension, dyspnea or ventilator-dependence, congestive heart failure, disseminated cancer, bleeding disorder, and perioperative transfusion were significantly higher for non-OA group. Mechanical bowel preparation, minimally invasive surgery, conversion to open and operative duration ≥ 180 min were more prevalent in the OA group. The OA group had significantly reduced occurrence of CDI; superficial, deep, and organ space infections; wound disruption; anastomotic leak; reoperation; and infections including sepsis, septic shock, pneumonia, and urinary tract infection. On multivariable analysis, OA reduced the odds for CDI after colectomy (OR = 0.6, 95% CI = [0.5-0.8]). For patients who did not develop infectious postoperative complications, OA was associated with lower risk of CDI (OR = 0.7, CI = [0.5-0.9]). While complications, reoperation, and readmission rates were the same, postoperative ileus and hospital stay were significantly lower for those who developed CDI after receiving OA when compared to non-OA. CONCLUSION: The use of OA as bowel preparation may reduce, rather than increase, the risk of 30-day CDI after colectomy. This effect may partly be due to the other recovery advantages associated with oral antibiotics. These data further support current data recommending the use of oral antibiotics for bowel preparation before colectomy.