Same-Day Discharge for
Colorectal Surgery:
ERAS 2.0
Sender Liberman, MD
Professor of Surgery & Oncology
McGill University Health Centre
Friday, April 21
st
MSQC & ASPIRE Collaborative meeting, Ann Arbor, Michigan
Conflicts of Interest
• Abbott Nutrition (speaker: ERAS)
• Takeda (clinical research)
Objectives: After this session, participants will
gain an overview of the
pathway towards Same
Day Discharge
1
understand the benefits
of day surgery for
colorectal resections for
the patient, the
hospital, and the
healthcare system.
2
better understand how
digital technology can
facilitate patients' early
discharge from the
hospital.
3
Outline
Quick intro to ERAS
MUHC experience with SDD
Lessons learned
Prehab
Enhanced Recovery After Surgery
• Decreased length of stay
• Decreased complications
• Decreased healthcare
resource utilization
• Increased patient
satisfaction
MUHC Experience
• Colorectal ERAS since 2008
• Multiple iterations
• Multiple new pathways across specialties
• Target LOS 2-3d
• 66% discharged within target LOS
Pecorelli et al. Surg Endosc. 2016
Overall adherence
n=347 elective colorectal surgery
Adherence to enhanced recovery pathway elements is associated with
successful recovery and reduction in 30-day complications
- costly
+ effective
+ costly
+ effective
- costly
- effective
+ costly
- effective
Cost-effectiveness of Enhanced Recovery versus Conventional
Perioperative Management for Colorectal Surgery
Each point represents 1 bootstrap estimate Lee et al. Ann Surg. 2015 Dec;262(6):1026-33
ERPs : beyond reducing length of hospital stay and complications?
Lost days from work 35(20) vs 26(18)*
Caregiver lost days from work 5(12) vs 1.3(2.6)*
Postoperative CLSC visits, n 3.7(9) vs 1.4 (4.6)*
Institutional cost saving -$1,150 (-3487 to 905)
Health care system cost saving -$1,602(-4,050 to 517)
Society cost saving -$2,985(-5,753 to -373)*
Lee et al. Ann Surg. 2015 Dec;262(6):1026-33
ERPs- specific costs (design, implementation and audit): 153 $ per patient
How can we do better?
Traditional care Enhanced Recovery Outpatient surgery
Does this guy really need to stay???
Has this been done before?
• <2% of all colectomies in ACS-NSQIP
discharged within 23h (out of >100k
cases)
Saadat et al. World J Surg 2020
• ~4% of ileostomy reversals in ACS-NSQIP
discharged within 23h (out of ~25k
cases)
Taylor et al. J Gastrointest Surg 2019
Has this been done before?
• Home visit by a nurse BID x 5 days then
DIE x5 days
• Another daily check-up phone call x5
days
• CRP on POD 1, 3, 7
Gignoux et al. Ann Surg 2019
Inclusion criteria
• Laparoscopic colectomy
• “Good” general condition
• No serious comorbidities
• “Full patient understanding”
Exclusion criteria
• Low rectal
• Right colectomy
• Large T4 tumours
• Prev perforated diverticulitis
• Prev midline laparotomy
Gignoux et al. Ann Surg 2019
“Ambulatory”
protocol required
significant outpatient
resources
Retrospective review
• February 2019-August 2021
• 69 patients, 1 readmission (1.4%)
• LAR x 32, Right hemicolectomy x 11
• All robot-assisted, no conversions
Curfman KR, et al, Ambulatory colectomy: A pilot protocol for same
day discharge in minimally invasive colorectal surgery. Am J Surg.
2022 Aug;224(2):757-760
MUHC Outpatient Colectomy Protocol
Main outcome: ER visit
within 72h (standard ERP
target LOS 3d)
Stopping criteria: >35%
ER visits within 72h
- 35% baseline incidence
of complications
Outpatient Colectomy – Discharge Criteria
• Tolerating PO intake (at least 300cc of clear fluids)
• No nausea/vomiting
• Minimal anti-emetics
• Pain is adequately controlled on PO analgesia
• Able to pee
• Able to ambulate
MUHC Experience
• 1
st
patient Feb 13, 2020
• 69M
• Laparoscopic right colectomy for malignancy
• 4cm Pfannenstiel extraction incision, TAP block
• OR time: 93 minutes
• PACU time: 7h 15min
• Fentanyl 25 mcg IV x3 (=22.5 MME)
• Ketorolac 30mg IV
• ~1 patient per week
MUHC SDD Colectomy Protocol
MUHC SDD
361 patients undergoing
laparoscopic colectomy
172 consented and
managed by SDD
47% of overall
laparoscopic
colectomy volume
MUHC SDD
172 consented and
managed by SDD
26 patients needed to be
admitted (15%)
14 patients required an
ED visit within 72h (8%)
157 SDD success
(77%)
Baseline stats
(Jan/17 – July/19)
30d ED visits: 18%
30d readmission: 8%
(July/19 – Sept 20)
30d ED visits: 15%
30d readmission: 7%
Baseline stats
(Jan/17 – July/19)
30d ED visits: 18%
30d readmission: 8%
(July/19 – Sept 20)
30d ED visits: 15%
30d readmission: 7%
Overall 30-day ED visits: 19%
Overall 30-day readmissions: 11%
Update
Update
Successful SDD 90% (n=160)
Reason for ED Visit 72Hr
Ileus (n=5)
Bleeding per rectum (n=4)
Urinary Retention (n=3)
SBO (n=1)
Pain (n=1)
Seroma (n=1)
Fever (n=1)
Types of Procedures for SDD
RHC/Ileocecectomy 32% (n=70)
Sigmoidectomy 23.6% (n=51)
Low Anterior Resection 13.8% (n=30)
Stoma Reversal 30% (n=65)
Essential Elements / Lessons Learned
1. Patient selection
2. Post-discharge follow-up
3. Pain control
4. GI ”dys”function
Patient Selection
>25% are ASA 3+
15% extraperitoneal
rectal anastomosis
Phone, email,
or app
* High health literacy / engagement
BRIEF Health Literacy Screen
Score range 4-20
Limited health literacy: 4-12
Marginal health literacy: 13-16
Adequate: 17-20
Dumitra et al. JAMA Surg 2021
Low activation (PA levels 1 & 2)
- More unplanned visits
- aOR 3.15 (95% CI 2.05-4.86)
- More time off work
- Longer LOS
- More complications
Patient activation
No difference in app usage between high (87%)
and low engagement (94%)
Number of communications similar between
groups
Application Usage
Results – SDD Cohort
30-Day Emergency Department Visits
30-Day Complication Rates
Patients with
low engagement had increased 30-
day ED visits 38% compared to 7% for those with
high engagement (p-value 0.04)
30-Day Complication rates higher in patients with
low engagement 38% compared to 7% for those
with high engagement (p-value 0.04)
Patient activation
• Patient engagement had no impact on success of digital health app follow-
up after elective colorectal surgery
• Low patient engagement associated with ↑ 30-day ED visits + complications
in a subset of SDD patients
Low Patient Engagement
Complications and ED Visits
Digital Health Application
Am J Surg 2021
Limited health literacy
- More complications
- SSI
- Longer LOS
Patient Selection
• Preoperative education
• Pain control = tolerable
• Ok to have some nausea
• Patient expectations
• “My friend/parent had
this surgery 10 years ago
and they stayed a
week!”
• Get everyone on board
• Caretaker!
* High health literacy / engagement
Essential Elements / Lessons Learned
1. Patient selection
2. Post-discharge follow-up
3. Pain control
4. GI ”dys”function
**Common theme**
Concerns about access to healthcare
provider/information if
complications/concerns arise after
discharge
CareSense – Post-Discharge Remote
Monitoring
mHealth Apps
Post-Discharge Remote Monitoring
• Patient education booklet
• Daily 5-item questionnaire up to POD7
• Is your pain controlled with oral pain pills?
• Are you able to drink liquids without nausea?
• Are you passing gas or bowel movements?
• Do you have a fever?
• Is your wound leaking?
• HIPAA-compliant Patient-Physician communication feature
Easy Access Communication
1. Patients love it
• >90% felt safer with this function
2. Platform/medium doesn’t matter
• Mobile app
• Telephone
• Email
**as long as someone answers**
Lee et al. Surg Endosc 2022
3. Patients don’t abuse it
• Avg # messages in first 7 days:
13.8 (incl. responses)
CareSense – Post-Discharge Remote
Monitoring
Eustache et al. DCR 2021
Lower number of ED visits in
APP+, but same number of
readmissions
- able to identify adverse
events through app-based
interactions
CareSense – Post-Discharge Remote
Monitoring
• High satisfaction
• High useability
• System Useability Scale 84.5 (SD 17.6)
• Improved communication
• 88% felt that the app improved their ability to communicate with their
surgeon
**Average number of
messages per patient in the
first 7 days: 6.9
Ann Surg 2021
mHealth
mHealth remote follow-up after colorectal surgery is feasible & not
associated with a high user burden
May decrease unnecessary ED visits
High satisfaction
Essential Elements / Lessons Learned
1. Patient selection
2. Post-discharge follow-up
3. Pain control
4. GI ”dys”function
Pain Control
485 patients were included with 42% TAP block versus 58%
without
Specimen extraction incisions (SEI) were midline (11%),
transverse (11%) and Pfannenstiel (78%)
TAP blocks were independently associated with a significant
decrease in opioid use on both POD0 and POD1, but not
beyond
TAP was independently associated with -6.8 MME (95%CI: -
11.2,-2.3) on POD0 and -13.0 MME (95%CI -18.0,-8.1) on
POD1 after adjusting for SEI and other confounders
SEI had no impact on opioid requirements
Stephan Robitaille MD, Anna Wang MD, Naser Al-Ali, Hiba Elhaj, A. Sender Liberman MD, Patrick Charlebois MD, Barry Stein
MD, Liane S. Feldman MD, Julio F. Fiore Jr PhD , Lawrence Lee MD PhD, Does specimen extraction incision and transversus
abdominus plane block affect opioid requirements after laparoscopic colectomy? *Unpublished data
Essential Elements / Lessons Learned
1. Patient selection
2. Post-discharge follow-up
3. Pain control
4. GI ”dys”function
GI ”dys”function
Is Clear Fluid (CF) diet tolerated on POD-0?
221 patients, 69% CF+ and 31% CF-
CF- more likely in IBD
• fewer complications (19% vs. 35%, p = 0.009)
• shorter mean LOS (mean 3.6d (SD 2.9) vs. 6.2d (SD 9.4),
p = 0.002)
• More likely to be discharged by the target LOS (66% vs.
50%, p = 0.024)
The CF+ group
CF+ on POD-0 = potential criteria for SDD
Leung VWY, Baldini G, Liberman S, Charlebois P, Stein B, Feldman LS, Fiore JF Jr, Lee L. Tolerating clear fluids diet on
postoperative day 0 predicts early recovery of gastrointestinal function after laparoscopic colectomy. Surg Endosc. 2022
Dec;36(12):9262-9272. doi: 10.1007/s00464-022-09151-8. Epub 2022 Mar 7. PMID: 35254522.
Provider/Healthcare System Benefits
Hospital costs
SDD << standard inpatient ERP
COVID-19 Hospitalizations October 2020
++ elective surgery
cancellations
SDD allowed patients to
get their surgery even with
limited inpatient hospital
capacity
- Shorter delays to
surgery
- ”Better” cancer
outcomes
Still relevant with ongoing
human resource limitations
Future Directions
• Health wearables integration for true remote monitoring
HR >100, T >38.5, no activity
HR >100, T 37, ↑ activity
How can we improve eligibility for SDD?
Prehabilitation
WHERE DOES THIS FIT IN? CAN WE IMPROVE SDD
RATE?
Undernutrition Before Surgery: Our
Experience.
Gillis C, Carli F . Nut Clin Pract 2015
Global Assessment (n=70) score A refers to adequately nourished; B moderate or
suspected undernutrition; C severely undernourished
A
B
C
8%
29%
63%
The incidence of undernutrition in all patients attending preoperative clinic at
Montreal General Hospital for elective colorectal surgery
High readmission
rate
Malnutrition
Exercise
(Caspersen et al., 1985)
Physical fitness: a set of attributes that are either health or skill related. The
degree to which individuals possess (or do not possess) these attributes can
be measured with specific tests.
Exercise: physical activity that is planned, structured, performed
regularly/repetitively and has a goal of improving or maintaining physical
fitness = Quantifiable
Physical activity: any bodily movement produced by skeletal muscle that
results in energy expenditure = “Movement”
can be measured (kcal)
occupational, sports, conditioning,
household or other activities.
Further defining exercise: dose
For the (pre) surgical patient,
exercise is especially important
Muscle
atrophy
and
weakness
Components of
McGill
Multimodal
Prehabilitation
4-week home-based
aerobic + resistance +
flexibility exercises
Protein
1.2 – 1.5 gr/kg
Anxiety
Management
Smoking
Cessation
Can Prehab improve SDD rates?
• Strengthening candidacy for
same day discharge colorectal
surgery: A multi-centered mixed
methods study (Grant
submitted)
Same-day discharge for colorectal
surgery: looks promising
Digital health technologies are central
Patient, provider, and healthcare
benefits
Prehabilitation may expand the
candidacy range for SDD
