Enhanced Recovery Pathways Decrease Length of Stay Following Colorectal Surgery But How Quickly Do Patients Actually Recover?

A Neville, MD, A S Liberman, MD, P Charlebois, MD, B Stein, MD, A Ncuti, BSc, M C Vassiliou, MD, G M Fried, MD, L S Feldman, MD. McGill University Health Center


Background: Enhanced recovery pathways (ERP) are associated with decreased complications and shorter hospital stay after colorectal surgery. While many studies evaluating recovery report length of stay as the primary outcome, duration of hospitalization does not necessarily reflect the patients’ process of recovery to their baseline level of function following the physiologic stress of surgery. The purpose of this study was to evaluate recovery following colorectal surgery within an ERP using a physical activity questionnaire (The Community Health Activities Model Program for Seniors [CHAMPS]).

Methods: CHAMPS, a validated measure of postoperative recovery, is a questionnaire where patients report time spent doing physical activity over the course of a week. Responses are converted into caloric expenditure (kcal/kg/wk). A 3kcal/kg/wk difference is equivalent to 1 hour of moderate intensity activity. This questionnaire was administered preoperatively and 6 weeks post-operatively to patients undergoing elective colorectal surgery within the framework of a multimodal ERP between September 2009 and February 2011. Data are presented as mean (sd) or median [25th,75th percentile]. Statistical significance was defined as p<0.05.

Results: Fifty-four patients with complete follow-up data were analysed. Of these patients 54.0% were male and the mean age was 59.0 (17.9) years. The mean BMI was 26.2 (5.7) kg/m2 and 77.4% of patients underwent surgery for neoplastic disease. All patients received perioperative care within the framework of an ERP; 75.9% of procedures were performed laparoscopically. The median length of stay was 4[3,7] days. Physical activity decreased from a median of 30.7 [17.5, 60.8] kcal/kg/wk preoperatively to a median of 25.2 [16.9, 44.8] kcal/kg/wk at 6 weeks postoperatively (p=0.03). Overall, only 53.7% of patients were back to or above baseline physical activities at 6 weeks. Length of stay was not significantly correlated with physical activity at 6 weeks (Spearman correlation coefficient= -0.23). However, more patients who left the hospital on or before postoperative day 4 were more likely to have recovered to baseline physical activity at 6 weeks than those who left after postoperative day 4 (67.7% vs 34.8%, p=0.03).

Conclusion: This study highlights the limitations of using length of stay as a primary outcome measure when evaluating recovery within an ERP. While length of stay was short, a significant proportion of patients were not fully recovered at 6 weeks postoperatively. In order to assess post-discharge outcomes, novel measures such as physical activity should be considered in the assessment of innovations aimed at improving recovery. 

Session Number: Poster – Poster Presentations
Program Number: P107
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