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  • 1. Delayed GI Recovery Following Colectomy
    Anthony J. Senagore, MD, MBA, MS, FACS, FASCRS
     Vice President and Chief Academic Officer
    Spectrum Health Medical Group
     
    Professor of Surgery
    Michigan State University
    College of Human Medicine
    East Lansing, Michigan
  • 2. Faculty Disclosure
    It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.
    Dr. Senagore has received grants/research support from Deltex Medical, ElectroCore Medical, LifeCell Corporation, and NiTi Surgical Solutions. He has served as a consultant for Ethicon, Inc and Tranzyme Pharma and has received honoraria from Adolor, Covidien, and GlaxoSmithKline.
  • 3. Educational Learning Objectives
    Describe the importance of improving time to gastrointestinal recovery that occurs postsurgery and consider how this affects length of hospital stay and overall quality of patient care
    Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures
    Describe how interprofessional collaboration surrounding gastrointestinal surgery can result in better alignment with current surgical quality measures and formulate strategies to integrate this into current practice
  • 4. Case Presentation
    • 55-year-old WM with complicated sigmoid diverticulitis and several percutaneous drainage procedures for abscess
    • 5. He presents now for an elective open sigmoid colectomy
  • Patient Case–Postoperative Course
    • He develops abdominal distention with oral liquids on postoperative Day 4 and vomits a large volume of bilious fluid
    • 6. He has been on intravenous fentanyl PCA analgesia
    PCA: patient-controlled analgesia
  • 7. Patient Case POD 5−9
    • He has continued NG aspirates of 1200–1500 ml per day
    • 8. A PICC line is placed and he is placed on total parenteral nutrition for nutritional support
    • 9. He undergoes daily complete metabolic profiles and alternate day CBC’s to monitor his status
    • 10. A CT scan is done on Day 7 to exclude abdominal abscess
    PICC: peripherally inserted central catheter
  • 11. Patient Case POD 9−13
    • He begins to pass flatus on POD 9 and his NG aspirate slowly decreases
    • 12. He begins clear liquids on POD 10 and is finally advanced to general diet and after a bowel movement is able to be discharged home on POD 13
  • Large Bowel Resection Accounts
    Disproportionately for Surgical Morbidity
    Schilling P, et al. J Am Coll Surg. 2008;207:698-704.
  • 13. Elective Colorectal Surgeries
    And Length of Stay
    What is the typical length of stay associated with elective bowel resection procedures?
  • 14. International Mean Length of Stay: Still Long
    Mean stay in days
    Base = US: 232, UK: 173, France: 120, Germany: 216, Italy: 174, Spain: 167
    Kehlet H, et al. J Am Coll Surg. 2006;202:45-54.
  • 15. Why the Outliers (? POI)
    The data demonstrate variable LOS, however POI was not recorded as a complication in this data set
    A
    O/E
    Ratio
    95% Confidence Interval
    Outlier (P < 0.05)
    Extended LOS in the Absence of Complications
    Worse than Expected
    Better than Expected
    Hospital
    Cohen ME, et al.Ann Surg. 2009;250:901-907.
  • 16. Clinical and Financial Significance
    • HCFA data (Medicare): 1999–2000
    • 17. 161,000 major intestinal/colorectal resections
    • 18. Mean post-op stay = 11.3 days
    • 19. 1.8 million hospital bed-days
    • 20. $1.75 billion per annum
    Senagore AJ. Am J Health-Syst Pharm. 2007;64(S13):S3-7.
  • 21. Elective Colorectal Surgeries
    and Length of Stay
    Although numerous studies have demonstrated that accelerated care pathways for colorectal surgeries are associated with reduced length of hospital stay, length of stay in the US and elsewhere is ~7-15 days. Gastrointestinal recovery is an important determinant of length of stay.
  • 22. Elective Bowel Resection and Perioperative Surgical Care Pathway
    A recent web-based survey of general and colorectal surgeons in the US indicated that only 30% practice in hospitals with a perioperative surgical care pathway intended to accelerate GI recovery following elective bowel resections
    Delaney C, et al. Am J Surg. 2010;199:299-304.
  • 23. Fast Track Protocol
    • Pre-operative information and education
    • 24. No NG, +/- epidurals
    • 25. PCA analgesia, supplementary i.v. ketorolac
    • 26. Encouraged to ambulate x 5 per day
    • 27. Liquids ad lib after surgery
    • 28. Diet from evening post-op Day 1
    • 29. Oral analgesia Day 2 if tolerating diet
  • Nasogastric Tube Usage(more than you think)
    Kehlet H, et al. J Am Coll Surg. 2006;202:45-54.
  • 30. Time to General Diet(slower than you think)
    Kehlet H, et al. J Am Coll Surg. 2006;202:45-54.
  • 31. There Are Numerous Risk Factors for POI
    Extent of Bowel Manipulation
    Surgical Site
    POI is Expected to Affect Almost Every Patient Who Undergoes Abdominal Surgery
    Amount of Opioids
    Operation Time
    Resnick J, et al. Am J Gastroenterol. 1997;92:751-762.
    Resnick J, et al. Am J Gastroenterol. 1997;92:934-940.
    Senagore AJ. Am J Health-Syst Pharm. 2007;64(suppl 13):S3-S7.
    Senagore AJ, et al. Surgery. 2007;142:478-486.
    Woods MS. Perspect Colon Rectal Surg. 2000;12:57-76.
  • 32. Delayed recovery
    Clinical Impact of POI1-4
    • Increased postoperative pain
    • 33. Increased nausea and vomiting
    • 34. Increased risk of aspiration
    • 35. Prolonged time to regular diet
    • 36. Delayed wound healing
    • 37. Increased risk of malnutrition/catabolism
    • 38. Prolonged time to mobilization
    • 39. Increased pulmonary complications
    • 40. Prolonged hospitalization
    • 41. Increased health care costs
    Woods MS. Perspect Colon Rectal Surg. 2000;12:57-76.
    Kehlet H, Holte K. Am J Surg. 2001;182(5A suppl):3S-10S.
    Behm B, Stollman N. Clin Gastroenterol Hepatol. 2003;1:71-80.
    Leslie JB. Ann Pharmacother. 2005; 39:1502-1510.
  • 42. GI Recovery and Cost Considerations
    What is the economic impact of delayed GI recovery following bowel resection procedures?
  • 43. 25
    15
    No coded POI
    No coded POI
    Coded POI
    Coded POI
    20
    10.6
    16.3
    10
    15
    9.9
    5.4
    10
    5
    5
    0
    0
    Hospital LOS and Total Costs
    *
    *
    Mean hospital costs per patient, × $1,000
    Mean duration of hospital stay, days
    *P < 0.01 for patients with coded POI versus patients withno coded POI.
    Senagore AJ, et al. ASCRS 2005 Annual Meeting, Philadelphia, PA.
  • 44. Economic Burden of POI Associated With Abdominal Surgery
    Cumulative costs for coded POI (total hospitalization + readmission cost) = $1,464,167,173
    Data from Premier’s Perspective Comparative Database,160 Hospitals, 2002
    Goldstein J, et al. P&T. 2007;32(2):82-90.
  • 45. Cost Data I.Index Admission: SH Colectomy
    * P < 0.05 ANOVA
    Asgeirsson T, et al. J Am Coll Surg. 2010;210:228-231.
  • 46. Cost Data II.Readmission: SH Colectomy
    No statistical significance ANOVA
    Asgeirsson T, et al. J Am Coll Surg. 2010;210:228-231.
  • 47. Cost Data III.Total Cost of Care for Entire Cohort
    Patients with primary POI and readmission for delayed primary POI accounted for 35% of the total costs, despite being only 24% of the study population
    Asgeirsson T, et al. J Am Coll Surg. 2010;210:228-231.
  • 48. Postoperative ileus increases cost primarily due to what reason?
    A. Increased rate of anastomotic leak
    B. Increased use of imaging and laboratory investigation
    C. Increased risk of incisional dehiscence
    D. Increased cost of analgesics
  • 49. POI and Costs
    Additional costs associated with POI primarily include increasing length of stay, labor costs, imaging/diagnostic studies, laboratory costs, and parenteral nutrition
  • 50. GI2* Recovery Following Bowel Resection
    *GI2 = time to toleration of solid food and first bowel movement
    CI = confidence interval
    http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/021775s004lbl.pdf. Accessed May 2010.
  • 51. GI Recovery Data From 5 Bowel Resection Studies
    1.0
    Alvimopan 12 mg
    Placebo
    0.9
    0.8
    0.7
    0.6
    Estimated Probability of
    Achieving GI-2 Recovery
    0.5
    0.4
    Increased risk of prolonged POI in the placebo group
    0.3
    0.2
    0.1
    0.0
    0
    24
    48
    72
    96
    120
    144
    168
    192
    216
    240
    264
    Hours After End of Surgery
    Wolff BG, et al. Ann Surg. 2004;240:728-735.
    Delaney CP, et al. Dis Colon Rectum. 2005;48:1114-1125.
    Viscusi E, et al. Surg Endosc. 2006;20:67-70.
    Ludwig K, et al. Arch Surg. 2008;143:1098-1105.
    Buchler M, et al. Aliment Pharmacol Ther. 28:312-325.
    http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/021775s004lbl.pdf. Accessed May 2010.
  • 52. Enhanced Recovery Pathway
    Departmental Length of Stay (LOS)
    1991–1999 1999 March–June/2000
    n LOS n LOS n LOS
    DRG 148
    ERP open 1784 9.5 185 8.6 62 5.7*
    other CR teams 6459 9.8 824 8.8 162 10.1
    Laparoscopic243.2*
    DRG 149
    ERP open 742 6.4 69 5.2 44 3.5†
    other CR teams 2256 6.4 327 5.1 111 4.5
    Laparoscopic 18 2.5*
    DRG 148 & 149
    ERP open 2526 8.6 254 7.7106 4.7§
    other CR teams 8715 8.9 1151 7.7 273 7.7
    Laparoscopic 42 2.9 *
    * P < 0.0001; † P = 0.002; §P < 0.001, Student’s t test
    LAP: laparoscopy
    CR: colorectal surgery
    Delaney C,et al. Br J Surg. 2001;88:1533-1538.
  • 53. Laparoscopic Colectomy at a Single Institution–Outcomes
    Senagore AJ, et al. Am J Surg. 2006;191:377-380.
    EBL: estimated blood loss
  • 54. DRG 148 Assignment
    70
    60
    50
    40
    30
    20
    10
    0
    Laparoscopy
    Open
    Preop Comorbidities
    Postop Complications
    The data demonstrate that the incidence of assignment to DRG 148 was due to postoperative complications at twice the frequency in open colectomy compared to laparoscopic colectomy (orange bars).
    The majority of these complications were postoperative ileus.
    *P < 0.001
    *
    Patient
    no.
    *
    DRG 148: colorectal resection with complications
    Senagore AJ, et al. Dis Colon Rectum. 2005;48:1016-1010.
  • 55. Professional Margin:
    Fee v OR Time: Improved Contribution Margin
    Senagore A. Personal Communication
  • 56. GI Recovery, LOS, and Cost
    • GI recovery influences LOS, which impacts overall hospitalization costs
    • 57. Strategies to enhance GI recovery are expected to ultimately translate into cost savings
    • 58. Enhanced recovery pathway
    • 59. Preoperative patient education and optimization
    • 60. Minimally invasive surgery where appropriate
    • 61. Early removal of NG tubes
    • 62. Early resumption of diet
    • 63. Opioid-sparing techniques
    • 64. Peripheral opioid antagonism where appropriate
    • 65. Early ambulation
  • Patient Case Summary
    Patient developed prolonged POI with an extended length of stay
    Increased cost of care due to imaging, parenteral nutrition, and metabolic monitoring
    Patient experienced significant impairment of quality of life and delayed recovery
  • 66. Conclusion
    • POI accounts disproportionately for cost of care following colectomy and impacts upwards of 20% of the patient population
    • 67. Safe and effective reduction in the incidence of POI will reduce cost and resource consumption in colectomy