JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES Volume 24, Number 6, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/lap.2013.0258
Early Discharge Following Transanal Endoscopic Microsurgery Is Safe Christopher J. Wright, MBChB, FRCS, MSc, and Matthew Tutton, MBBS, BSc, FRCS, MS
Aim: Transanal endoscopic microsurgery (TEM) was developed as an alternative to major surgery for rectal tumors; however, there is no consensus as to the optimal postoperative length of stay. The aim of this large series is to show that a policy of presumed early discharge is safe. Patients and Methods: All patients undergoing TEM at a single center between 2008 and 2011 were included. Data on demographics, tumor morphology, length of stay, and complications were collected from a prospectively collected database and computer records. Results: Sixty-six patients were included, with a mean tumor size of 4.6 cm (range, 0.6–10 cm). The majority were adenomas (71%). Median stay was 1 day, with most (77%) patients being discharged within the 23-hour policy. Neither age nor tumor size affected the length of stay. There were five complications (7.6%), and 2 patients (3%) required readmission following discharge. No complications arose in patients discharged within 23 hours. Conclusions: The majority of patients were safely discharged within 23 hours. No early-discharge patient suffered complications or required readmission. The overall complication rate was consistent with other published series, and neither age nor tumor size adversely affected outcome. A routine 23-hour discharge policy can thus be recommended for TEM patients.
ransanal endoscopic microsurgery (TEM) was developed during the 1980s as an alternative to major surgery in the treatment of rectal tumors. Previously alternatives included repeated endoscopic resection or ablation, which can be painful for very low tumors, or radical rectal resection, with all the risks associated with major pelvic surgery. With the advent of TEM it became possible to consider a single potentially curative operation. One aspect of TEM that remains to be definitively established is the optimal length of stay in hospital following surgery. Several large studies have reported mean hospital stays of 4–5 days for patients undergoing TEM, with morbidity rates in the range of 7%–8% and low readmission rates.1–3 Some articles have also shown that 23-hour discharge is safe, although the number of patients in these studies is small.4 The next question is whether TEM is suitable for day-case surgery, which offers advantages for patients and healthcare providers, providing that is safe. Regardless, there is certainly interest in reducing hospital stay to fully realize
the benefits of TEM. However, there is still differing opinion among centers as to what constitutes a safe length of hospital stay. This series demonstrates that early discharge is safe and should be considered the default position for patients undergoing TEM. Patients and Methods
A tertiary TEM service was established in a district general hospital in 2008. This service was offered by a single consultant surgeon. All patients undergoing TEM were included in the study. All patients receive full bowel preparation with two doses of sodium picosulfate (Picolax; Ferring Pharmaceuticals, West Drayton, Middlesex, UK) as per the local policy for preparation of patients for colonoscopy. Apart from the initial few cases, the default position was that patients were sent home the morning after surgery (23-hour discharge) unless contraindicated, irrespective of bowel function. All patients were given 5 days of oral antibiotics following TEM. A prospectively collated database was
Department of Colorectal Surgery, Colchester General Hospital, Colchester, United Kingdom.
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analyzed, and individual datasets were completed where necessary by examining computer records to obtain data on demographics, length of stay, 30-day readmissions, and complications. Results
Sixty-six consecutive cases were identified. Table 1 shows the demographics of the population. Forty were male (61%). The median age was 67 years (range, 28–87 years); 27 patients (41%) were over 70 years of age, and 10 (15%) were 80 years old or over. Forty-one patients (71%) had adenomas, 18 (21%) had cancers, and 1 had a stricture following previous traditional transanal resection. Most of the cancers were polyp cancers or T1 adenocarcinomas, but there were 2 patients with T2 tumors (1 patient proceeded to subsequent radical resection) and 1 patient with a T3 tumor who underwent a palliative resection. Almost all patients (n = 61) underwent a full-thickness resection, and all defects were closed with sutures. The submucosal resections were early in the series and hence were treated under the same protocol as the full-thickness resections in terms of discharge. The decision to resect most lesions by full-thickness resection is partly due to ease of closure of defect and partly to obviate any potential deleterious effects of unexpected malignancy within the polyp being incompletely excised. None of the resections entered the peritoneal cavity—all were below the peritoneal reflection, with the lowest resection being at just 1 cm above the dentate line, although the precise height of resection was not recorded in the database. Resection margins were clear for all cases. The median length of stay was 1 day (range, 1–31 days). Overall, 77% of patients were discharged on postoperative Day 1, and 88% were home by Day 2 (Fig. 1). It is noteworthy that even the majority of the earliest cases in the present series had a longer hospital stay. This represents a short learning curve in the postoperative management of TEM patients. Age was not significantly related to prolonged admission (Fig. 2). There was no significant relationship between length of stay and age using linear regression analysis (t = 2.02; difference not significant).
Frequency of length of stay (days).
The mean tumor diameter was 4.6 cm (range, 0.6–10 cm) (Fig. 3), and nearly half of the tumours (44%) were 5 cm in size or greater—so-called ‘‘giant adenomas.’’5 There was no significant correlation between size of tumor and hospital stay (P = 0.187) (Fig. 4), with no significant difference for patients with smaller (< 5 cm; n = 37) and larger (q5 cm; n = 29) tumors (for 1.32 and 2.92 days, respectively; P = .084). There were two readmissions (3%), both for bleeding. One patient settled with conservative management, although the other was treated by return to the operating room and subsequently stayed in the hospital for 11 days (a 80-year-old patient who subsequently needed postdischarge care arrangements, which further significantly delayed discharge). Neither patient had been discharged on a 23-hour basis as bleeding had been a problem intraoperatively, and they had been kept hospitalized for prolonged observation. There were no deaths, and the overall morbidity rate was 7.6% (5 patients). Other complications included bleeding requiring transfusion. One patient had discomfort and had subcutaneous emphysema, which was treated conservatively. One patient had pelvic sepsis, which eventually required a defunctioning stoma, which was subsequently reversed, and this patient was hospitalized for 31 days. None of the complications occurred in patients discharged within 23 hours. Although there was a trend toward a higher morbidity rate in patients with larger tumors, this was not significant: < 5 cm versus q5 cm, two complications (5.4%) versus four complications (13.8%) (v2 = 1.658, P = .198).
Table 1. Patient Demographics Demographic Age range (years) 20–29 30–39 40–49 50–59 60–69 70–79 80–89 Mean Male/female ratio ASA I II III ASA, American Society of Anesthesiologists.
Value 1 0 6 4 28 17 10 66 40/26 22 36 8 FIG. 2.
Length of stay (days) versus age (years) of patient.
EARLY DISCHARGE FOLLOWING TEM IS SAFE
Tumor size (cm) distribution.
The results from this series show that it is safe to discharge the majority of patients following TEM for rectal tumors within 23 hours of surgery. Indeed, adopting a presumptive policy of discharging all patients following TEM on this basis is safe as patients who developed complications were all recognized within this time frame. Despite the considerably shorter hospital stay reported in this series, the morbidity and mortality rates were consistent with those published in other series.1–3 Patient selection for TEM is important to avoid undertreating those who would benefit from more radical surgery, such as those with rectal cancers beyond the T1 stage, and to avoid overtreating those suitable for simple, curative endoscopic therapy. This series would seem to suggest that this balance has probably been achieved in that only 1 patient subsequently needed radical surgery and that the adenoma sizes were relatively large, implying that they were less amenable for endoscopic management. Perhaps surprisingly, patient age had no detrimental effect on the ability to safely discharge the patient within 23 hours.
There were 2 cases where a slight delay in discharge occurred because of ‘‘social’’ or discharge planning issues related to elderly patients, but the vast majority of elderly patients were safely discharged within 23 hours as planned. This highlights the fact that TEM surgery is safe, regardless of the age of the patient, although as always consideration must be given to fitness for anesthesia. Certainly, if one considers more radical surgery, many of the more elderly patients would likely not have been offered, or have agreed to, curative treatment otherwise. Tumor size and the use of full-thickness resection might have been expected to affect length of stay or complication rates adversely through increasing the technical difficulty; however, that was not borne out in this series. Morbidity rates were comparable to those in other large series,1–3,5 and early discharge was therefore safe, thus removing large tumor size as an indication for prolonged hospital stay. Finally, it is noteworthy that the current United Kingdom payment schedule for TEM surgery does not make provision for the length of stay per se, unlike cholecystectomy, for example, where the payment scale is higher for day-case procedures, and hence this was not a factor in making a discharge policy. Conclusions
A universal policy of presumptive 23-hour discharge for all patients undergoing TEM is safe and can be recommended. It is also recommended that patients be kept for prolonged observation if there is concern during the perioperative period. Many of these individuals will safely go home within the following 48 hours. The results of this and other studies would suggest the possibility of TEM in daycase surgery, given the appropriate safety procedures are in place. Disclosure Statement
Tumor size (cm) versus length of stay (days).
No competing financial interests exist. All authors contributed significantly and equally to the inception, development, performance, and writing up of the final article/manuscript.
1. de Graaf E, Doornebosch P, Tetteroo G, Geldof H, Hop W. Transanal endoscopic microsurgery is feasible for adenomas throughout the entire rectum: A prospective study. Dis Col Rectum 2009;52:1107–1113. 2. Koebrugge K, Bosscha K, Ernst M. Transanal endoscopic microsurgery for local excision of rectal lesions: Is there a learning curve? Dig Surg 2009;26:372–377. 3. Allaix M, Arezzo A, Caldart M, Festa F, Morino M. Transanal endoscopic microsurgery for rectal neoplasms: Experience of 300 consecutive cases. Dis Col Rectum 2009;52:1831–1836. 4. Ford S, Wheeler J, Borley N. Factors influencing selection for a day-case or 23-h stay procedure in transanal endoscopic microsurgery. Br J Surg 2010;97:410–414.
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5. Scala, A, Gravante G, Dastur N, Sorge R and Simson JN. Transanal endoscopic microsurgery in small, large, and giant rectal adenomas. Arch Surg 2012;20:1–8.
Address correspondence to: Christopher J. Wright, MBChB, FRCS, MSc Department of Colorectal Surgery Colchester General Hospital Turner Road Colchester CO4 5JL United Kingdom E-mail: [email protected]