The evolving role of staging laparoscopy in the treatment of colorectal hepatic metastasis.

HYPOTHESIS: Laparoscopy is an increasingly important tool in the staging and treatment of hepatic malignancies. This study evaluates the effect of staging laparoscopy (SL) using intraoperative ultrasonography (IOUS) on the regional treatment of isolated hepatic colorectal metastasis. DESIGN: Analytic cohort study. SETTING: Tertiary care center. PATIENTS: Consecutive patients who have a colorectal metastasis confined to the liver and selected for surgical regional treatment. INTERVENTIONS: All patients underwent preoperative evaluation followed by SL/IOUS. Operative plans were based on preoperative imaging and were either carried out or altered intraoperatively according to SL/IOUS findings. MAIN OUTCOME MEASURE: Effect of SL/IOUS on surgical management. RESULTS: Between September 1996 and May 2004 one hundred fifty-two SL/IOUSs were performed in 136 patients (77 males and 59 females), who had a mean (SD) age of 63 (11) years. Data sets were complete in 138 events. All patients had isolated hepatic disease as defined by preoperative computed tomography in 152 (100%) and positron emission tomography in 107 (70%). Staging laparoscopy/IOUS identified surgically untreatable disease in 34 events (25%) because of peritoneal metastases (n = 15), nodal involvement (n = 11), diffuse hepatic disease (n = 5), no identifiable disease (n = 2), and untreatable disease (n = 1). Laparoscopic treatment events included radiofrequency ablations (n = 78), hepatic artery pump implantations (n = 40), resections (n = 26), and combined procedures (n = 37). Overall, SL/IOUS changed the treatment plan in 66 (48%) of 138 of events. This includes 32 (23%) of 138 events in which SL/IOUS findings significantly altered the actual procedure performed relative to the preoperative plan. Three minor complications occurred in the SL/IOUS-only group with a mean (SD) hospital stay of 1.3 (1) days. CONCLUSION: In the regional management of isolated colorectal hepatic metastasis, SL/IOUS avoids unnecessary laparotomies and influences definitive surgical intervention in a substantial proportion of patients.

Prospective study of colorectal enhanced recovery after surgery in a community hospital.

IMPORTANCE: Enhanced recovery after surgery (ERAS) colorectal programs have shown to be successful at reducing length of stay in many international and academic centers; however, their efficacy in a community hospital setting remains unclear. OBJECTIVE: To determine if favorable results could be reproduced in a community hospital setting using our ERAS program, which was developed using core ERAS guidelines with the goal of accelerated recovery while also addressing other important outcomes affecting patient experience and safety. DESIGN, SETTING, AND PARTICIPANTS: Prospective study of ERAS program, a multidisciplinary effort involving anesthesia, preadmission staff, nursing, and surgery staff at a community hospital. The program was initiated in 2010 and was in full practice by 2011. We assessed practice patterns and patient outcomes for all elective colon and rectal resection cases performed in 2009 (prior to ERAS implementation), 2011, and 2012. MAIN OUTCOMES AND MEASURES: Laparoscopic approach, narcotic use, length of stay, 30-day readmission, ileus (defined as reinsertion of nasogastric tube), and intra-abdominal infection and association between colorectal cancer (CRC) diagnosis and these outcomes. RESULTS: From 2009 to 2012, the use of laparoscopy increased from 57.4% to 88.8% (P < .001). Length of stay decreased significantly (6.7 days vs 3.7 days, P < .001), without an increase in 30-day readmission rate (17.6% vs 12.5%, P = .49). Use of patient-controlled narcotic analgesia and duration of use decreased (63.2% of patients vs 15%, P < .001; 67.8 hours vs 47.1 hours, P = .02). Ileus rate decreased from 13.2% to 2.5% (P = .02). Intra-abdominal infection decreased from 7.4% to 2.5% (P = .24). When comparing laparoscopic cases alone, similar results were observed. Following regression analysis, there were no statistically significant differences between CRC diagnosis and LOS, 30-day readmission rates, ileus, and intra-abdominal infection (all P's > .05). Length of stay reductions resulted in an estimated cost savings of $3202 per patient (2011) and $4803 per patient (2012). CONCLUSIONS AND RELEVANCE: Implementation of this patient care-directed enhanced recovery program is feasible in a community hospital setting, and it is associated with decreased LOS without increased readmission or morbidity, as well as significant decreases in narcotic use and cost. Improved outcomes are independent of the laparoscopic approach and CRC diagnosis.