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
He presents now for an elective open sigmoid colectomy

5. Patient Case–Postoperative Course
He develops abdominal distention with oral liquids on postoperative Day 4 and vomits a large volume of bilious fluid
He has been on intravenous fentanyl PCA analgesia
PCA: patient-controlled analgesia

6. Patient Case POD 5−9
He has continued NG aspirates of 1200–1500 ml per day
A PICC line is placed and he is placed on total parenteral nutrition for nutritional support
He undergoes daily complete metabolic profiles and alternate day CBC’s to monitor his status
A CT scan is done on Day 7 to exclude abdominal abscess
PICC: peripherally inserted central catheter

7. Patient Case POD 9−13
He begins to pass flatus on POD 9 and his NG aspirate slowly decreases
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

8. Schilling P, et al. J Am Coll Surg. 2008;207:698-704.
Large Bowel Resection Accounts
Disproportionately for Surgical Morbidity
Schilling P, et al. J Am Coll Surg. 2008;207:

9. Elective Colorectal Surgeries
And Length of Stay
What is the typical length of stay associated with elective bowel resection procedures?

10. 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.

11. Extended LOS in the Absence of Complications
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:

12. Clinical and Financial Significance
HCFA data (Medicare): 1999–2000
161,000 major intestinal/colorectal resections
Mean post-op stay = 11.3 days
1.8 million hospital bed-days
$1.75 billion per annum
Senagore AJ. Am J Health-Syst Pharm. 2007;64(S13):S3-7.

13. 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.

14. 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:

15. Fast Track Protocol Pre-operative information and education
No NG, +/- epidurals
PCA analgesia, supplementary i.v. ketorolac
Encouraged to ambulate x 5 per day
Liquids ad lib after surgery
Diet from evening post-op Day 1
Oral analgesia Day 2 if tolerating diet

16. Nasogastric Tube Usage (more than you think)
Kehlet H, et al. J Am Coll Surg. 2006;202:45-54.

17. Time to General Diet (slower than you think)
Kehlet H, et al. J Am Coll Surg. 2006;202:45-54.

18. There Are Numerous Risk Factors for POI
Surgical Site
Extent of Bowel Manipulation
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:
Resnick J, et al. Am J Gastroenterol. 1997;92:
Senagore AJ. Am J Health-Syst Pharm. 2007;64(suppl 13):S3-S7.
Senagore AJ, et al. Surgery. 2007;142:
Woods MS. Perspect Colon Rectal Surg. 2000;12:57-76.

19. Clinical Impact of POI1-4
Increased postoperative pain
Increased nausea and vomiting
Increased risk of aspiration
Prolonged time to regular diet
Delayed wound healing
Increased risk of malnutrition/catabolism
Prolonged time to mobilization
Increased pulmonary complications
Prolonged hospitalization
Increased health care costs
Delayed recovery
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:

20. GI Recovery and Cost Considerations
What is the economic impact of delayed GI recovery following bowel resection procedures?

21. Hospital LOS and Total Costs
9.9
16.3 5 10 15 20 25
No coded POI
Coded POI
5.4
10.6 5 10 15
No coded POI
Coded POI * *
Mean hospital costs per patient, × $1,000
Mean duration of hospital stay, days
*P < 0.01 for patients with coded POI versus patients with no coded POI.
Senagore AJ, et al. ASCRS 2005 Annual Meeting, Philadelphia, PA.

22. Economic Burden of POI Associated With Abdominal Surgery
Coded POI
Without Coded POI
Total number of procedures (%)
142,026 (8.5%)
1,519,663 (91.5%)
Average length of stay (days)
11.5
5.5
Cost per hospital stay
$18,877
$9,460
Number of readmissions (%)
5,113 (3.6%)
304 (0.02%)
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.

23. Cost Data I. Index Admission: SH Colectomy
Primary POI (N = 38)
Secondary POI (N = 7)
Non-POI
(N = 141)
Average cost/admission
$15,914
$17,311
*$8,316
Hospital
$7,258
$6,794
*$3,165
Pharmacy
$2,639
$3,588
*$454
Radiology
$153
$324
$37 OR
$4,823
$5,433
$4,260
Labs
$579
$741
*$252
Other
$485
$420
*$146
* P < 0.05 ANOVA
Asgeirsson T, et al. J Am Coll Surg. 2010;210: 23

24. Cost Data II. Readmission: SH Colectomy
Delayed POI
(N = 9)
Other Complications
(N = 18)
Average cost/admission
$ 3,546
$6,670
Hospital
$3,088
$4,890
Pharmacy
$217
$371
Radiology
$58
$125 OR
---
$670
Labs
$171
$257
Other
$357
No statistical significance ANOVA
Asgeirsson T, et al. J Am Coll Surg. 2010;210: 24

25. 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: 25

26. 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

27. POI and Costs
Additional costs associated with POI primarily include increasing length of stay, labor costs, imaging/diagnostic studies, laboratory costs, and parenteral nutrition

28. GI2* Recovery Following Bowel Resection
Study
Placebo
(Mean h)
Alvimopan 12 mg
Difference
Hazard Ratio
(95% CI) 1
111.8
92.0
19.8
1.533 (1.293, 1.816) 2
132.0
105.9
26.1
1.625 (1.256, 2.102) 3
130.3
116.4
14.0
1.365 (1.057, 1.764) 4
119.9
106.7
13.2
1.400 (1.035, 1.894) 5
109.5
98.8
10.7
1.299 (1.070, 1.575)
*GI2 = time to toleration of solid food and first bowel movement
CI = confidence interval
Accessed May 2010.

29. 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 24 48 72 96
120
144
168
192
216
240
264
Hours After End of Surgery
Wolff BG, et al. Ann Surg. 2004;240:
Delaney CP, et al. Dis Colon Rectum. 2005;48:
Viscusi E, et al. Surg Endosc. 2006;20:67-70.
Ludwig K, et al. Arch Surg. 2008;143:
Buchler M, et al. Aliment Pharmacol Ther. 28:
Accessed May 2010.

30. Enhanced Recovery Pathway Departmental Length of Stay (LOS)
1991– March–June/2000
n LOS n LOS n LOS
DRG 148
ERP open *
other CR teams
Laparoscopic *
DRG 149
ERP open †
other CR teams
Laparoscopic *
DRG 148 & 149
ERP open §
other CR teams
Laparoscopic *
* P < ; † P = 0.002; § P < 0.001, Student’s t test
LAP: laparoscopy
CR: colorectal surgery
Delaney C, et al. Br J Surg. 2001;88:

31. Laparoscopic Colectomy at a Single Institution–Outcomes
Number of Cases
BMI
OR Time (minutes)
EBL (mL)
Conversion (%)
Length of Stay
(mean/median days)
Right Colectomy
314
29.2 88 95 9
3.5/3.0
Left Colectomy
435
28.9
118
110 12
3.8/2.0
Total Colectomy 61
25.7
189
185 11
4.1/3.0
Other
190
28.1
115
120 10
3.9/2.0
All
1000
28.3
112
135
3.7/2.0
Senagore AJ, et al. Am J Surg. 2006;191:
EBL: estimated blood loss

32. The majority of these complications were postoperative ileus.
DRG 148 Assignment
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 * 10 20 30 40 50 60 70
Laparoscopy
Open
Preop Comorbidities
Postop Complications
Patient
no. *
Senagore AJ, et al. Dis Colon Rectum. 2005;48:
DRG 148: colorectal resection with complications

33. Fee v OR Time: Improved Contribution Margin
Professional Margin:
Fee v OR Time: Improved Contribution Margin
Senagore A. Personal Communication

34. GI Recovery, LOS, and Cost
GI recovery influences LOS, which impacts overall hospitalization costs
Strategies to enhance GI recovery are expected to ultimately translate into cost savings
Enhanced recovery pathway
Preoperative patient education and optimization
Minimally invasive surgery where appropriate
Early removal of NG tubes
Early resumption of diet
Opioid-sparing techniques
Peripheral opioid antagonism where appropriate
Early ambulation

35. 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

36. Conclusion
POI accounts disproportionately for cost of care following colectomy and impacts upwards of 20% of the patient population
Safe and effective reduction in the incidence of POI will reduce cost and resource consumption in colectomy