The clinical and economic implications of same day discharge compared to enhanced recovery protocols following minimally invasive colectomy and stoma reversal

Introduction: Enhanced recovery protocols (ERP) after minimally invasive (MIS) colorectal surgery are associated with faster return of gastrointestinal function, shorter lengths of stay (LOS), and reduced complications. Same day discharge (SDD) after colorectal surgery is the next step in the evolution of ERP. While evidence supports the safety and feasibility of SDD compared to ERP, a proportion of patients experience SDD failure. Importantly, factors predicting failure and financial consequences of these programs remains unclear. Objectives: Identify predictors of SDD failure/success and identify the cost implications of SDD at the institutional level for patients undergoing MIS colectomy or stoma reversal. Methods: Ethics approval was obtained from McGill University Health Centre. Patients who underwent elective MIS colectomy or ostomy reversal at a tertiary colorectal centre between 01/2020 and 03/2023 were eligible for SDD with remote post-discharge follow-up. Eligibility criteria included minimal comorbidities, hospital proximity, home support, and smartphone ownership. Patients meeting the criteria were discharged on the day of surgery if they had adequate oral analgesia, tolerance of liquids, independent ambulation and voiding, and absence of complications. Data was collected prospectively, and successful SDD patients were compared to those who failed to identify factors associated with SDD success or failure using univariate and regression analyses. Coarsened exact matching (CEM) was used to create comparable patient groups undergoing SDD versus ERP following MIS colectomy or ostomy reversal. These groups were matched for age, body mass index (BMI), sex, Charlson Comorbidity Index, and procedure. The CEM algorithm was adjusted to achieve a state of balance between the two groups. The ERP cohort consisted of a retrospective group of patients who underwent MIS colectomy or ostomy reversal at the same centre as the initial study, from 08/2017 to 03/2022. These patients were subject to the same inclusion criteria as those undergoing SDD. Institutional costs were calculated through a microcosting technique from the time of surgery to 30-days postoperatively. Uncertainty was conveyed through 10,000 bootstrapped estimates. Results: A total of 175 patients(85.3%) achieved successful SDD, while 44(21.5%) failed. The SDD failure group exhibited higher Charlson Comorbidity Index(3.7, 2.8,p-value=0.03). Mean LOS(0.8, 3.0,p-value=0.00), 30-day complications(10%, 48%,p-value=0.00) and readmissions(8%, 27%,p-value=0.00) were significantly higher in the SDD failure group. Regression analysis revealed that failed SDD was associated with increased comorbidity burden(OR 0.79, 95%CI 0.66, 0.95) and longer Post Anesthesia Care Unit time(OR 0.99, 95% CI 0.99, 0.99). Individuals who received a regional nerve block(OR 4.1, 95%CI 1.2, 14) and those who did not require postoperative opioids(OR 4.6, 95%CI 1-21) were more likely to achieve successful SDD. During the study period, a total of 689 patients underwent colectomy or stoma reversal(121 SDD, 568 ERP), with 305 patients included after matching(96 SDD, 209 ERP). Cost analysis revealed savings of $1,817(95%CI -3021 to -613) per patient for SDD colectomy and 2344$(95%CI -3838 to 851) for stoma reversal. Most cost savings were observed in ward, pharmaceutical, and allied healthcare expenses. Total LOS was significantly shorter in SDD patients undergoing colectomy with no difference in those undergoing stoma reversal compared to the ERP cohort. Emergency department visits were higher in SDD patients undergoing stoma reversal, with no significant difference in those undergoing colectomy compared to the ERP cohort. Conclusion: Overall, SDD is safe, effective, and associated with an institutional cost savings in select patients. Our findings underscore the importance in careful patient selection as those with increased comorbidities and prolonged PACU stays are at increased risk of SDD failure

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