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Original Investigation
November 3, 2021

Assessing Criteria for a Safe Early Discharge After Laparoscopic Colorectal Surgery

Author Affiliations
  • 1Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France
  • 2Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
  • 3EMR 37-38, Lyon 1 University, Lyon, France
  • 4Department of Digestive and Oncological Surgery, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France
JAMA Surg. Published online November 3, 2021. doi:10.1001/jamasurg.2021.5551
Key Points

Question  Do patients who fulfill 5 criteria 2 or 3 days after laparoscopic colorectal surgery (a C-reactive protein level <150 mg/dL on the day of discharge, a return of bowel function, tolerance of a diet, pain less than 5 of 10 on a visual analog scale, and being afebrile during the entire stay) have a lower risk of developing an anastomotic leak and can therefore be discharged early?

Findings  This cohort study included 287 adults. Two of 15 anastomotic leaks occurred in patients that fulfilled the criteria vs 13 of 15 in patients who did not, a significant difference.

Meaning  These 5 criteria could determine who is eligible for early discharge after laparoscopic colorectal surgery.

Abstract

Importance  Early discharge after colorectal surgery has been advocated. However, there is little research evaluating clinical and/or laboratory criteria to determine who can be safely discharged early.

Objective  To evaluate the diagnostic performance of a C-reactive protein (CRP) level combined with 4 clinical criteria in ruling out an anastomotic leak and therefore allowing an early discharge on postoperative day 2 or 3.

Design, Setting, and Participants  This prospective, single-center cohort study was performed between February 2012 and July 2017. All consecutive adult patients undergoing laparoscopic colorectal surgery were included. All patients were followed up for 30 days postoperatively. Data analysis was performed in May 2021.

Exposures  Whether the 5 discharge criteria were fulfilled on postoperative day 3 (or day 2 for patients discharged on day 2). Fulfillment was defined as a CRP level less than 150 mg/dL on the day of discharge, a return of bowel function, tolerance of a diet, pain less than 5 of 10 on a visual analog scale, and being afebrile during the entire stay.

Main Outcomes and Measures  The primary outcome measurement was the diagnostic performance of the 5 discharge criteria in anticipating anastomotic leak development. The diagnostic performance of CRP level alone and 4 clinical criteria alone was also evaluated. Secondary measures were anastomotic leaks and mortality rates up to postoperative day 30. A discharge was successful if the patient left the hospital on postoperative day 2 or 3 without any complications or readmissions.

Results  A total of 287 patients were included (median [IQR] age, 58 [20] years; 141 men [49%] and 146 women [51%]). Mortality was 0%. There were 17 anastomotic leaks, of which 2 were on day 1 and were excluded. A total of 128 patients fulfilled all criteria, and 125 did not, including 34 for whom data were missing. Two leaks occurred in patients who had fulfilled all criteria vs 13 leaks in patients who did not (hazard ratio, 0.15 [95% CI, 0.03-0.69]; P = .01). Seventy-six of 128 patients (59.4%) were discharged successfully by postoperative day 3. The negative predictive value in ruling out an anastomotic leak was at least 96.9% for CRP alone (96.9% [95% CI, 93.3%-98.8%]), the 4 clinical criteria (98.4% [95% CI, 95.3%-99.7%]), and all 5 criteria combined (98.4% [95% CI, 94.5%-99.8%]). False-negative rates were 40% (95% CI, 16.3%-67.7%) for CRP level alone, 20% (95% CI, 4.3%-48.1%) for the other 4 criteria, and 13.3% (95% CI, 0%-40.5%) for all 5 criteria.

Conclusions and Relevance  These 5 criteria have a high negative predictive value and the lowest false-negative rate, indicating they have the potential to allow for safe early discharge after laparoscopic colorectal surgery.

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