Surgeons at University Hospitals Case Medical Center, Cleveland, are working to reduce serious complications that have been known to occur with colorectal operations. In addition to using a set of pre- and postoperative standards that speed recovery which they have been publishing on for more than a decade, the researchers have validated yet another step surgeons can take to further reduce patients' hospital stays: adding a procedure called the transversus abdominis plane (TAP) block to patients' surgical care.
The results of their study appear in the September issue of the Journal of the American College of Surgeons.
Aside from the pain and discomfort associated with colorectal operations, national studies show that more than one in 10 patients end up being readmitted to the hospital for complications within 30 days of the procedure. More than one in five will be back in the hospital after 90 days, according to a study published in Diseases of the Colon and Rectum. In an effort to improve outcomes and reduce readmissions, colorectal surgeon Conor P. Delaney, MD, PhD, FACS, FASCRS, has been among a group of surgeons who have been developing and testing Enhanced Recovery Pathways (ERP) for colorectal surgical patients.
The ERP protocol counters traditional conventions about how patients should prepare for, and recover from, colorectal operations. Dr. Delaney reported that these standardized steps -- which have been shown to speed recovery and improve outcomes -- include letting patients eat the day after the procedure instead of waiting several days, encouraging them to walk around after procedures instead of staying in bed, optimizing analgesia, and controlling intravenous fluid volumes.
Dr. Delaney looked at further reducing patients' postoperative pain by adding the TAP block. Although usually administered with ultrasound guidance, Dr. Delaney's group has recently described a laparoscopic tap block technique that enables surgeons to inject a regional analgesia into a layer of the abdominal wall between the oblique muscles and the transversus abdominis. The nerve block is given at the conclusion of colorectal operations and reduces pain in the operative area.
For the study, Dr. Delaney employed the Enhanced Recovery Pathway protocol and the TAP block on 100 patients in 2012. Sixty-five patients needed an operation after being diagnosed with colorectal neoplasia. Most of the other patients needed treatment for conditions like Crohn's disease, ulcerative colitis, and diverticulitis.
After the TAP block, patients were also given intravenous painkillers, including acetaminophen. The TAP block allows patients to bypass or at least reduce the barrage of narcotics they are often given after an operation. Though narcotics can help alleviate pain, Dr. Delaney said these agents can also slow down recovery. The TAP block, however, wears off just in time for patients to skip the worst of the pain that occurs immediately after the operation. The TAP block also does not appear to pose any significant risks to patients, Dr. Delaney added.
The researchers' goal was to see whether the TAP block reduced complications and shortened the hospital stay. Results showed that the mean hospital stay dropped to less than 2.5 days after the surgical procedure, significantly lower than the 3.7 days which the University Hospitals Case Medical Center Carepathway had already described for more than 1,000 consecutive patients. The researchers reported that 27 patients went home the next day and another 35 went home 48 hours after their operations. "That's a lot better than the five or six days patients usually stay in the hospital after laparoscopic colorectal procedures, and certainly better than nine days often seen after an open operation," Dr. Delaney said. "With a third of patient leaving the day after colorectal resection, we feel these results have been remarkable."
As Dr. Delaney's group has previously shown, there were no mortalities, and patients who stayed longer in hospital tended to have more complications. Of the eight patients with complications, such as urinary tract infections, gastrointestinal bleeds or a small bowel obstructions, only two of this group were discharged within 48 hours.
"The old thinking was that if patients went home early, they have a higher chance of readmission, but the data continue to show that's not the case," Dr. Delaney explained. "Patients who went home earliest had the lowest readmission rate."
Those patients who had complications or required a longer stay were probably more high-risk patients anyway, because of advanced age or additional health conditions, Dr. Delaney said. Standardized criteria for discharge from hospital also play an important role in these results.
Using a TAP block to reduce hospital stay and narcotics use also has implications for reducing health care costs. In addition to the cost of each day in hospital, painkillers and other medications for colorectal surgical patients can cost many hundreds of dollars for each patient, Dr. Delaney estimated. The TAP block costs just $20 per patient. "There are so many things we have to be careful of and cost is one of them," Dr. Delany said. "This is a low cost way to help patients feel better and recover sooner."
Dr. Delaney predicts that ERP protocols will become standard practice for colorectal surgical patients in the next five years, although some health care organizations are already using them to a variable extent. However, including TAP blocks in that protocol will require more evidence. "The next step is a randomized clinical trial," he said. In fact, Dr. Delaney's research team has already initiated a randomized double-blinded trial to compare a group of colorectal surgical patients who receive the TAP block with another group who will not.
"If things continue to go well, my expectation is that we'll eventually be giving the TAP to everyone, because it helps with reducing the pain," Dr. Delaney said. "As quality and outcomes improve, we will also continue to see an increasing percentage of patients who are fit to be discharged the day after colorectal resection."
- Joanne Favuzza, Conor P. Delaney. Outcomes of Discharge after Elective Laparoscopic Colorectal Surgery with Transversus Abdominis Plane Blocks and Enhanced Recovery Pathway. Journal of the American College of Surgeons, 2013; 217 (3): 503 DOI: 10.1016/j.jamcollsurg.2013.03.030
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