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The implementation of new protocols and guidelines for colorectal surgery in the University of Maryland Cancer Network is allowing patients to go home about two days sooner than expected, with lower incidence of complications and less need for opioid pain medication.

"We have patients undergoing colorectal surgery who would otherwise be expected to stay in the hospital for five to seven days, but who are going home on Day 1 and Day 2 with less blood loss, earlier recovery and no infection," says Cherif N. Boutros, MBChB, MSc, associate professor of surgery at the University of Maryland School of Medicine.

Across all University of Maryland Medical System (UMMS) hospitals, these evidence-based guidelines for enhanced recovery have led to lower infection rates, less postoperative pain, and improved overall outcomes for colorectal surgery patients.

Boutros is medical director of the Tate Cancer Center and chief of surgical oncology at UM Baltimore Washington Medical Center (UM BWMC), part of the University of Maryland Cancer Network and an affiliate of UMMS.

"The most recent data show we have an observed-versus-expected surgical site infection ratio of 0.48," Boutros says. "Patients with multiple medical problems carry a higher expected risk of surgical-site infection when they undergo resection of their colon or rectal cancer. UMMS current data show that we are able to reduce this risk to less than 50% of what is expected."

Advanced Techniques for Any Stage of Disease

Among patients in UMMS hospitals requiring colon cancer surgery, about 40% benefit from a minimally invasive approach with either laparoscopic or robotic surgery.

For patients with advanced disease, the network includes surgeons at the UM Greenebaum Comprehensive Cancer Center at University of Maryland Medical Center, where Andrea C. Bafford, MD, assistant professor of surgery at the UM School of Medicine, is the section chief for colorectal surgery.

"For patients with low-lying rectal cancers, specialists in colorectal surgery and surgical oncology can perform sphincter-preserving surgeries, avoiding permanent ostomies," Bafford says.

For patients with metastatic colorectal cancer, liver tumors can be treated with surgical removal or minimally invasive tumor-destroying procedures, including radiofrequency and microwave ablation. We also have nationally recognized experience in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) for cancer spread to the peritoneal membrane.

"The minimally invasive approach, the expertise to be able to preserve the sphincter, and the ability to take care of advanced cases when the cancer has spread -- that's what makes us stand out," Boutros says.

UMMS hospitals have been using laparoscopic and robotic surgery for colon cancer for several years.

"Unless I see evidence that a more involved surgery is needed, I always try to use a minimally invasive approach — robotic surgery or laparoscopic surgery," Boutros says. "If you have a less-invasive surgery, you have much less pain. To reduce narcotic consumption, we have increased our use of regional anesthesia to block the pain at the level of the abdomen, as well as injection of local anesthetic at the end of surgery."

Pain management continues into rehabilitation. "We use multimodal analgesia, with acetaminophen, gabapentin, non-steroidal anti-inflammatory drugs -- in consultation with the pharmacists -- with the common goal of pain control and reducing or eliminating the need for narcotics," Boutros says. "We provide a lidocaine infusion for the first 24-48 hours to enhance the patient's ability to participate in physical therapy and rehabilitation."

New National Guidelines to Enhance Recovery

ISCR Participating Facilities for Colorectal Cancer Surgery Average Length of Stay ChartBoutros attributes the improvements to multiple efforts, including access to clinical trials, focus on improved practices systemwide and participation in nationwide efforts. A year ago, UMMS hospitals adopted the new Improving Surgical Care and Recovery (ISCR) evidence-based guidelines sponsored by the American College of Surgeons.

Boutros says the patient outcomes data show better pain control, less need for opioids, shorter hospital stays, fewer complications and fewer surgical-site infections for colorectal surgery patients. The improvements apply to colorectal surgery for all indications, as well as in the specific population of patients with colon cancer.

The most current data show that postoperative complications are down by 50% and length of stay is 16% shorter from clinical year 2017 to clinical year 2018. In the last seven out of eight quarters, there were no surgical site infections.

About the ISCR

ISCR is a safety and quality-improvement program funded by the Agency for Healthcare Research and Quality and developed through collaboration between the American College of Surgeons (ACS) and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality. The ACS announced in February 2018 that data have been positive across the board for hospitals implementing the enhanced recovery program.

Furthermore, guidelines for standardizing the care of colorectal surgery patients have been established by the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. These guidelines were updated in 2017.

All UMMS Hospitals Implement ISCR Guidelines

UMMS hospitals have put the ISCR protocol into practice with involvement from their entire perioperative teams, including surgery, anesthesiology, nursing, pharmacy and physical therapy. All the UMMS hospitals follow gastrointestinal improvement guidelines based on ISCR, even if they are not officially enrolled in the ISCR protocol.

"The goal of the ISCR program is to improve the quality of care for patients who have colorectal surgery – not just for cancer," Boutros says. "The program enables the patient to have a shorter hospital stay, much better pain control and fewer surgical site infections. One of the reasons we started the program was out of a systemwide effort to reduce the incidence of surgical-site infections for colorectal patients."

The Guidelines in Practice

The ISCR guidelines encompass the full scope of surgical care and include preoperative measures such as patient education about the operation, bowel preparation plus perioperative antibiotics, and postoperative steps including early removal of the urinary bladder catheter on Day 1 to prevent catheter-related urinary tract infections.

Better pain control has been achieved by using robotic and laparoscopic surgery due to the smaller incision required for the operation. Patients are transitioned early from narcotics to acetaminophen, NSAIDs and gabapentin, reducing unnecessary risk of opioid dependence. In addition, the anesthesia team uses regional anesthesia and lidocaine infusions to control pain perioperatively and for participation in postoperative physical therapy and rehabilitation. Early oral nutrition and mobility is very important in getting the patient better faster and home faster.

Cases of Metastatic Colon Cancer

In cases of metastatic colon cancer, surgeons with the necessary expertise can offer liver resection or resection of the peritoneum, as well as several other surgical methods.

"There are a lot of variables for cancer that has spread to the liver. We cannot do it the same way for every patient," Boutros says.

The plan for surgery is based on the number, size and distribution of the liver metastasis. It also depends on the volume of the remnant liver after resection to assure liver function is still preserved. The quality of this liver remnant also is expected to be reduced secondary to underlying liver disease including fatty liver or previous chemotherapy.

"We have the expertise to be able to offer minimally invasive surgery," he says, "and the expertise to offer liver resection for colon and rectal cancer spread to the liver and the expertise to be able to preserve the sphincters in patients undergoing surgery for rectal cancer."

Want to take advantage of the UM Cancer Network's expertise? Refer a patient.