Why still in hospital after laparoscopic colorectal surgery within an enhanced recovery programme?

AIM: Enhanced recovery after surgery programmes in elective colorectal surgery have been developed and implemented widely, but a subgroup of patients may still require longer hospital stays than expected. The aim of this study was to identify and describe factors compromising early postoperative recovery by asking 'why is the patient still in hospital today?' after laparoscopic colorectal cancer surgery within an enhanced recovery after surgery programme. METHOD: Patients undergoing elective laparoscopic colorectal cancer resection were evaluated postoperatively with predefined potential reasons for still being in hospital. The primary outcome was 'reason for still being in hospital' on postoperative day 0-4 and secondarily length of stay with a focus on differences between patients with and without a stoma. RESULTS: Ninety-six patients having colorectal cancer surgery were included. The median length of stay for the whole group was 3 days (range 1-14). The four dominant causes for patients without a stoma to be in hospital were lack of gastrointestinal function, lack of early mobilization, lack of normal micturition and nausea. Patients with a stoma stayed in hospital due to stoma training, lack of gastrointestinal function, lack of free micturition and a miscellaneous 'others' group. CONCLUSION: Delayed gastrointestinal function, insufficient mobilization, poor urinary function and stoma care training have been characterized as dominant compromising factors for postoperative recovery. Together with a focus on frailty, future studies should focus on improving early mobilization, prevention and treatment of postoperative urinary retention and improved stoma care training, in order to minimize delay in postoperative recovery and discharge.

Hypoxaemia during recovery after surgery for colorectal cancer: a prospective observational study.

Episodic and ongoing hypoxaemia are well-described after surgery, but, to date, no studies have investigated the occurrence of episodic hypoxaemia following minimally-invasive colorectal surgery performed in an enhanced recovery setting. We aimed to describe the occurrence of postoperative hypoxaemia after minimally-invasive surgery in an enhanced recovery setting, and the association with morphine use, incision site, fluid intake and troponin increase. We performed a prospective observational study of 85 patients undergoing minimally-invasive surgery for colorectal cancer between 25 August 2016 and 17 August 2017. We applied a pulse oximeter with a measurement rate of 1 Hz immediately after surgery either until discharge or until two days after surgery, and recorded the oxygen saturation. We measured troponin I during the first four days after surgery, or until discharge. The median (IQR [range]) length of stay was 3 (2-4 [1-38]) days. Thirty-six percent of patients spent more than 1 h below an oxygen saturation of 90% (4.2% of the day), and with a median (IQR [range]) proportion of 1.3 (0.2-11.1 [0.0-21.4])% of the day spent with an oxygen saturation below 88%. We found no associations between time spent below an oxygen saturation of 88% and morphine use (p = 0.215), fluid intake (p = 0.446), complications (p = 0.808) or extraction site (p = 0.623). Postoperative increases in troponin I were associated both with time spent below an oxygen saturation of 88% (p = 0.026) and hypopnoea episodes (p = 0.003). Even with minimally-invasive surgery and enhanced recovery after surgery, episodic hypoxaemia and hypopnoea episodes are common, but are not associated with morphine use, fluid intake or incision site. Further studies should investigate the relationship between hypoxaemia and troponin increase.