Department of Surgical Oncology, Lyon Sud University Hospital, Hospices Civils de Lyon, Lyon, France.
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana.
JAMA Surg. 2022 Jan 1;157(1):52-58. doi: 10.1001/jamasurg.2021.5551.
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.
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.
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.
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.
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.
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.
提倡结直肠手术后早期出院。然而，很少有研究评估临床和/或实验室标准，以确定谁可以安全地早期出院。
评估 C 反应蛋白（CRP）水平与 4 项临床标准相结合，以排除吻合口漏并允许术后第 2 或 3 天提前出院的诊断性能。
设计、地点和参与者：这是一项前瞻性、单中心队列研究，于 2012 年 2 月至 2017 年 7 月进行。所有接受腹腔镜结直肠手术的连续成年患者均被纳入。所有患者在术后 30 天内接受随访。数据分析于 2021 年 5 月进行。
术后第 3 天（或第 2 天出院的患者为第 2 天）是否满足 5 项出院标准。满足标准定义为出院当天 CRP 水平<150mg/dL、恢复肠道功能、耐受饮食、疼痛视觉模拟评分<5 分且整个住院期间无发热。
主要结局测量是 5 项出院标准预测吻合口漏发展的诊断性能。还评估了 CRP 水平和 4 项临床标准单独的诊断性能。次要测量指标为吻合口漏和术后 30 天内的死亡率。如果患者在无任何并发症或再次入院的情况下在术后第 2 或 3 天出院，则出院成功。
共纳入 287 例患者（中位数[IQR]年龄，58[20]岁；男性 141 例[49%]，女性 146 例[51%]）。无死亡病例。发生吻合口漏 17 例，其中 2 例发生在第 1 天，被排除在外。共有 128 例患者满足所有标准，125 例患者不满足，其中 34 例患者数据缺失。在满足所有标准的患者中发生 2 例吻合口漏，而在不满足所有标准的患者中发生 13 例吻合口漏（危险比，0.15[95%CI，0.03-0.69]；P=0.01）。在 128 例满足条件的患者中，76 例（59.4%）在术后第 3 天成功出院。单独 CRP 排除吻合口漏的阴性预测值至少为 96.9%（96.9%[95%CI，93.3%-98.8%]），4 项临床标准（98.4%[95%CI，95.3%-99.7%]）和所有 5 项标准联合（98.4%[95%CI，94.5%-99.8%]）。CRP 水平单独的假阴性率为 40%（95%CI，16.3%-67.7%），其他 4 项标准为 20%（95%CI，4.3%-48.1%），所有 5 项标准为 13.3%（95%CI，0%-40.5%）。
这些 5 项标准具有较高的阴性预测值和最低的假阴性率，表明它们有可能在腹腔镜结直肠手术后安全地提前出院。
