Techniques in Coloproctology

, Volume 22, Issue 3, pp 191–199 | Cite as

The impact of complications after elective colorectal resection within an enhanced recovery pathway

  • L. LeeEmail author
  • S. Liberman
  • P. Charlebois
  • B. Stein
  • P. Kaneva
  • F. Carli
  • L. S. Feldman
Original Article



Despite the implementation of enhanced recovery pathways (ERP), morbidity following colorectal surgery remains high. The aim of the present study was to estimate the impact of postoperative complications on excess hospital length of stay (LOS) in patients undergoing elective colorectal resection.


A retrospective study of patients undergoing elective colorectal surgery at a single institution from 2003 to 2010 was performed. Patients managed by an ERP were compared to conventional care (CC), matched by propensity score radius matching. Complications were defined a priori. Excess (independent effect on LOS from multivariate analysis) and attributable (absolute number of additional bed days) LOS of common postoperative complications determined the impact of complications on bed utilization. Multivariate analysis was performed using multiple linear regression.


A total of 810 propensity-score-matched patients were included (ERP = 472, CC = 338). Complications were significantly lower in the ERP group compared to the CC group (20 vs. 31%, p < 0.001). Median LOS decreased from 7 days in the CC group to 5 days in the ERP group [adjusted decrease in mean LOS of 2.8 days (95% CI 0.8, 4.8)]. Anastomotic leak, myocardial infarction and C. difficile infection had the highest excess LOS for both the ERP and CC groups. However, impaired gastrointestinal function had a higher impact on the absolute number of hospital bed days in the ERP group, as high as anastomotic leak (72.7 vs. 73.5 days respectively), while in the CC group the impact of gastrointestinal dysfunction was less of that of anastomotic leak (50.6 vs. 78.9 days respectively).


In the setting of an ERP, postoperative complications have significant impact on total bed utilization. Impaired gastrointestinal function, given its high incidence, accounted for almost the same number of additional hospital bed days as anastomotic leak in the ERP group and is a target for quality improvement.


Treatment outcome Epidemiology Enhanced recovery pathway Preoperative care Length of stay Postoperative complications 



Salary support for LL was provided by the Fonds de Recherche en Santé—Québec and the McGill Surgeon Scientist program.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study protocol was approved by the institutional review board.

Informed consent

For this type of study formal consent is not required.


  1. 1.
    Schilling PL, Dimick JB, Birkmeyer JD (2008) Prioritizing quality improvement in general surgery. J Am Coll Surg 207(5):698–704. CrossRefPubMedGoogle Scholar
  2. 2.
    Khan NA, Quan H, Bugar JM, Lemaire JB, Brant R, Ghali WA (2006) Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med 21(2):177–180. CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Carey K, Stefos T, Shibei Z, Borzecki AM, Rosen AK (2011) Excess costs attributable to postoperative complications. MCRR 68(4):490–503. PubMedGoogle Scholar
  4. 4.
    Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 16(2):CD007635. Google Scholar
  5. 5.
    Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H (2000) A clinical pathway to accelerate recovery after colonic resection. AnnSurg 232(1):51–57Google Scholar
  6. 6.
    Kehlet H (2008) Fast-track colorectal surgery. Lancet 371(9615):791–793. CrossRefPubMedGoogle Scholar
  7. 7.
    Carli F, Charlebois P, Baldini G, Cachero O, Stein B (2009) An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can J Anaesth 56(11):837–842. CrossRefPubMedGoogle Scholar
  8. 8.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG (1992) CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 20(5):271–274CrossRefPubMedGoogle Scholar
  10. 10.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213. CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Dehejia RH, Wahba S (1999) Causal effects in nonexperimental studies: reevaluating the evaluation of training programs. JASA 94(448):1053–1062CrossRefGoogle Scholar
  12. 12.
    Austin PC (2009) Some methods of propensity-score matching had superior performance to others: results of an empirical investigation and Monte Carlo simulations. Biom J 51(1):171–184. CrossRefPubMedGoogle Scholar
  13. 13.
    Asgeirsson T, El-Badawi KI, Mahmood A, Barletta J, Luchtefeld M, Senagore AJ (2010) Postoperative ileus: it costs more than you expect. JACS 210(2):228–231. Google Scholar
  14. 14.
    Andersen HK, Lewis SJ, Thomas S (2006) Early enteral nutrition within 24 h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 4:CD004080. Google Scholar
  15. 15.
    DiFronzo LA, Yamin N, Patel K, O’Connell TX (2003) Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg 197(5):747–752. CrossRefPubMedGoogle Scholar
  16. 16.
    Maessen JM, Hoff C, Jottard K et al (2009) To eat or not to eat: facilitating early oral intake after elective colonic surgery in the Netherlands. Clin Nutr 28(1):29–33. CrossRefPubMedGoogle Scholar
  17. 17.
    Pillai P, McEleavy I, Gaughan M et al (2011) A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy. J Urol 186(6):2201–2206. CrossRefPubMedGoogle Scholar
  18. 18.
    Vaughan-Shaw PG, Fecher IC, Harris S, Knight JS (2012) A meta-analysis of the effectiveness of the opioid receptor antagonist alvimopan in reducing hospital length of stay and time to GI recovery in patients enrolled in a standardized accelerated recovery program after abdominal surgery. Dis Colon Rectum 55(5):611–620. CrossRefPubMedGoogle Scholar
  19. 19.
    Vasquez W, Hernandez AV, Garcia-Sabrido JL (2009) Is gum chewing useful for ileus after elective colorectal surgery? A systematic review and meta-analysis of randomized clinical trials. J Gastrointest Surg 13(4):649–656. CrossRefPubMedGoogle Scholar
  20. 20.
    Iyer S, Saunders WB, Stemkowski S (2009) Economic burden of postoperative ileus associated with colectomy in the United States. J Manag Care Pharm 15(6):485–494. PubMedGoogle Scholar
  21. 21.
    Boccola MA, Lin J, Rozen WM, Ho YH (2010) Reducing anastomotic leakage in oncologic colorectal surgery: an evidence-based review. Anticancer Res 30(2):601–607PubMedGoogle Scholar
  22. 22.
    Kehlet H (2008) Postoperative ileus–an update on preventive techniques. Nat Clin Pract Gastroenterol Hepatol. 5(10):552–558. CrossRefPubMedGoogle Scholar
  23. 23.
    Story SK, Chamberlain RS (2009) A comprehensive review of evidence-based strategies to prevent and treat postoperative ileus. Dig Surg 26(4):265–275. CrossRefPubMedGoogle Scholar
  24. 24.
    Gustafsson UO, Scott MJ, Schwenk W et al (2013) Guidelines for perioperative care in elective colonic surgery: enhanced recovery after surgery (ERAS(R)) society recommendations. World J Surg 37(2):259–284. CrossRefPubMedGoogle Scholar
  25. 25.
    Garfinkle R, Abou-Khalil J, Morin N et al (2017) Is There a Role for Oral Antibiotic Preparation Alone Before Colorectal Surgery? ACS-NSQIP Analysis by Coarsened Exact Matching. Dis Colon Rectum 60(7):729–737. CrossRefPubMedGoogle Scholar
  26. 26.
    Vlug MS, Wind J, Hollmann MW et al (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical trial (LAFA-study). Ann Surg 254(6):868–875. CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • L. Lee
    • 1
    • 2
    Email author
  • S. Liberman
    • 1
    • 2
  • P. Charlebois
    • 1
    • 2
  • B. Stein
    • 1
    • 2
  • P. Kaneva
    • 1
  • F. Carli
    • 1
    • 3
  • L. S. Feldman
    • 1
  1. 1.Department of Surgery, Steinberg-Bernstein Centre for Minimally-Invasive Surgery and InnovationMcGill University Health CentreMontrealCanada
  2. 2.Section of Colorectal Surgery, Department of SurgeryMcGill University Health CentreMontrealCanada
  3. 3.Department of AnaesthesiaMcGill UniversityMontrealCanada

Personalised recommendations