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Pandemic-related operating room closures, in part, due to a paucity of available hospital beds and a shortage of trained nurses to care for semi-elective surgical patients' inpatient needs, placed point pressure on providers and patients. These resource-limitations were the impetus for this team's creativity in accommodation. They took an existing protocol, which they coined “advanced-ERAS” (enhanced recovery after surgery), to an extreme for patients in need of colectomy. At the height of the pandemic, advanced-ERAS inpatient protocols pivoted – nearly overnight – to same day discharge.
This innovation was not without evaluation. Could patients be better served by spending post-operative-day-zero in the comfort (and safety!
A likely, albeit impossible-to-track, side benefit of this approach was decreased COVID exposure and transmission in this post-operative population who convalesced in social isolation.
1A likely, albeit impossible-to-track, side benefit of this approach was decreased COVID exposure and transmission in this post-operative population who convalesced in social isolation.
) of their own beds at home? In carefully-selected and skillfully, painstakingly-primed patients the answer was “yes”.
In this manuscript, the authors highlight a single-colorectal-surgeon's robotics practice [senior author L. Rashidi]. She tracked her cases and outcomes at two institutions in which she practiced after completion of fellowship training in colon and rectal surgery, with an emphasis in robotic surgery.
A longitudinal look at her cases, as explicitly detailed in this manuscript, showed a substantial increase in volumes (as enabled by single-surgeon's steep learning curve followed by steady-state mastery, combined with the team's efficiency), a marked decrease in the length of stay (from 5 days to 1 day) and significant increase in same day discharge rates (58% of all-comers in her robotic colectomy practice in the year 2021).
What impacted their trends was a change in institution mid-study (2018 was the year she transitioned
). I can only imagine how starting with a new employer and instituting culture norms around ERAS as it relates to colectomy took Herculean effort. This may have resulted in the downtrend that is illustrated in Fig. 1 and the spike seen in Fig. 2. What sent her trends into hyperdrive was the March 2020 initial pandemic lock-down in the U.S. Impressively, subsequent spikes in COVID which caused shutdowns for the rest of us may not have impacted her team as greatly, because of their prowess with their SDD protocol.
Also attributable to COVID's silver linings in this team's success with SDD was the normalization of telehealth. This team utilized it greatly, with routine pre-scheduled telehealth appointments on post-op day 1, 3 and 7 (with day 7 suggested as an in-person visit).
A major strength of the manuscript is that the sample size is large with a study population of 535 robotic surgery cases, 438 of which were colectomies. Another strength is that this team's SDD protocol is explicitly detailed in this manuscript and in their previous work.
Those of us who are in a contemplative phase have been provided what we need to emulate.
Curiosities which linger for me are related to several of the study's limitations. Namely, in terms of candidate selection for SDD, race and other social determinants of health are not yet available within this dataset. They will be critical factors to consider when evaluating whether implicit bias factors into selection. To foster health equity, what support can the hospital system (an entity which is presumably saving thousands of dollars by safely avoiding patients' inpatient stays) give to those who may not meet criteria due to health literacy issues, home support, and access to telecommunication technologies?
In sum, I tip my surgical scrub cap to this incredible effort by a talented team who did not compromise on quality and transparency. During the 2019-to-2021 time-period when they committed to this phenomenal push for SDD, this team also achieved center of excellence status from the National Accreditation Program for Rectal Cancer (NAPRC), a program of the American College of Surgeons Commission on Cancer (ACS-COC). They are the second institution in our state to achieve this distinction.
Full transparency of every rectal cancer patient's presentation and outcome within a hospital system over the previous 12 months is revealed before an accreditor's site visit is scheduled.
Maintaining quality (NAPRC) while pushing our boundaries and comfort zones (SDD) is what was demonstrated during this presentation at 2022's North Pacific Surgical Association in the author's home town of Tacoma, WA.
What's next? It won't be long before we see trending memes: “Coming soon to an ambulatory surgery center near you – colectomy.”
Declaration of competing interest
Neither myself nor my spouse have any financial relationships related to this manuscript or to my invited commentary to disclose.
I have no conflicts of interest to with the senior author, Dr. Laila Rashidi.
I did not train her in fellowship, nor do I work with her. I’m in the same health system (MultiCare), but in the Inland Northwest (in Spokane, WA), and not in Tacoma, WA. In Spokane, we do not have any ERAS protocols. In addition, my fee-based contract with MultiCare ends on 3/31/23, which may be around the time that this ms publishes. I did not list MultiCare as my institutional affiliation.
I wrote this with Washington State University as my institutional affiliation.
References
Vu M.M.
Curfman K.R.
Blair G.E.
Shah C.A.
Rashidi L.
Beyond enhanced recovery after surgery (ERAS): evolving minimally invasive colectomy from multi-day admissions to same-day discharge.
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