Enhanced Recovery Protocols (ERP) after large and small bowel resection are been used in several hospitals worldwide. The main reasons are economic, I think. They have the capability to reduce in hospital length of stay decreasing health care costs. Additionally postoperative complications are reported to be less with ERP.
One major point of these ERP is the date of first oral intake after surgery. According to some authors early oral intake can reduce ileus, however some report that early feeding as beginning oral diet in the second postoperative day, can overwhelm the gastrointestinal track causing severe ileus, increasing complications and increasing length of stay. This is true for about 12% of patients. In my own experience I have great difficulties in having my patients drinking in the second postoperative day... 12% only!? Of course that many other factors involved in the ERP are important to allow an early oral intake, like:
surgical technique (laparoscopy)
early mobilization/activity
prokinetic agents
non-opioid painkillers
bowel preparation
In all classic ERP, discharge criteria include tolerance to solid diet and return of bowel function with passage of flatus and stool. But... Is return of bowel function necessary for discharge? Does the patient need to tolerate solid diet so he can be discharged home?
Dr. Neal Ellis from the Texas Tech University Health Science Center in the USA, published this year in The American Journal of Surgery a case series trying to answer these questions. The author studied 94 patients operated between July 2012 and December 2014 by a single surgeon. Indications for operation were: carcinoma (92%), diverticulitis (7%), lower GI hemorrhage (1%). The procedures were: right colectomy (43%); low anterior resection (28%); left or sigmoid colectomy (25%); Miles operation (4%). For all 94 patients a ERP was used, including:
preoperative counseling for daily goals and discharge criteria
avoidance of oral antibiotics or mechanical bowel preparation
single dose of prophylactic antibiotic (Ertapenem)
perioperative opioid receptor blockers
laparoscopic technique (completed in 71% of patients) - conversion rate of 8%
non-steroidal anti-inflammatory drugs
patient controlled analgesia (PCA)
oral liquids immediately
Using as discharge criteria the tolerance of oral liquids with no need for intravenous fluids, Dr. Ellis report that 80% of patients were eligible for discharge in the second postoperative day and 100% in the third day. From those, passage of flatus was present in 63% and stools in 21%, meaning that 37% of patients had no bowel function at time of discharge. The author report an impressive average of in hospital postoperative length of stay of only 3,8 days, and a readmission rate of 8,5% within the 30 days following discharge. All cases of readmission were due to surgical site infection (SSI) and none because of ileus.
The results are impressive and lead to the conclusion that the "tolerance of a solid diet and return of GI function is not necessary prior to discharge". So, according to Dr. Neal Ellis data, tolerance to oral liquids with no need for intravenous fluids can be used as discharge criteria after colon resection.
About the 8,5% readmission rate because of SSI, the author states it is the same as compared to other ERP. He explains that because patient and doctor do not have the pressure for tolerating solid diet before discharge, it is less likely to overwhelm the GI tract and to develop ileus. It makes some sense to me, believing that the patient goes home and keeps on liquid diet for some more days. One issue I must focus is the antibiotic prophylaxis used by the author. How is it possible to use Ertapenem? Unbelievable! About bowel preparation, some doctors questioned Dr. Ellis if SSI rate would have been decreased if mechanical bowel preparation had been done. To this he answered that randomized studies did not concluded for any advantage. However, imagine there is an unexpected bowel perforation during surgery or you decide to extract the bowel through the rectum in laparoscopic sigmoid resection, and no mechanical bowel preparation was done. A fecal contamination will occur. Mechanical bowel preparation (there is no advantage but there is also no disadvantage) should be performed, I think.
Although more studies are warranted, I have some doubts that this will be the standard practice. Not so many patients will agree in being discharge before eating solids and having bowel function restored. We must not forget that in the USA patients and doctors are pressured by insurers, that want to spend the less money possible.
Even though, surgeons must be aware that oral intake can be initiated early in the postoperative period but other factors of ERP are important to fulfill so that diet can be tolerated. Additionally, anesthesiologists and nurses must be instructed about the Enhanced Recovery Protocols. Surgeons, anaesthesiologists and nurses must work as a well-tuned engine. This is the key for success!
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon