Hidden morbidity following colorectal resection:

postoperative evaluationG C Thorpe1 & J M Hernon2

1 School of Health Sciences, University of East Anglia, Norwich 2Norfolk & Norwich University Hospitals NHS Foundation Trust

Introduction

Methods

Results

Conclusion

References1Grocott MPW et al (2007) The Postoperative Morbidity Survey was validated and used to describe morbidity after pelvic surgery. Journal of Clinical Epidemiology 60: 919-9282Dindo, D. et al (2004) Classification of Surgical Complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Annals of Surgery 240(2):205-2133Spanjersberg, W.R. et al (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database of Systematic Reviews CD007635

Table 2: Patient questions to ascertain post-discharge SSISince leaving hospital, has (have) your wound(s):

• Been red/inflamed/hot/more painful?

• Opened? If so how much and how deep?

• Produced any discharge? If so how much, what was its appearance and did it smell?

• Been assessed by a healthcare professional who said it was infected?

• Required dressing (and packing)?

• Been swabbed?

Have you taken any antibiotics for your wound?

The implementation and evaluation ofEnhanced Recovery after Surgeryprogrammes over the past 15 yearshas ensured the accurate reporting ofinpatient morbidity post colorectalresection. However, there is a paucityof audit or research examining post-operative morbidity (POM) in theearly discharge period. A clinicalsurvey was conducted May-August2014, funded by Research CapabilityFunding, to ascertain the incidence ofpost-discharge morbidity followingcolorectal resection.

The sample comprised 142consecutive patients undergoingcolorectal resection (see table 1 forsample characteristics). Audit datawere collected on 138 patients in anurse-led outpatient clinic at 30 daysfollowing discharge. Data collectiontemplates were developed using thePostoperative Morbidity Survey1,Clavien-Dindo classification criteria2

and additional colorectal-specificevidence of post-operativemorbidity3. Templates were pilotedand modified to include additionaldata, such as information from theentire discharge period that couldindicate surgical site infection (SSI)(table 2). Results were recorded andanalysed using SPSS.

Findings suggest that individualsundergoing colorectal resectionexperience significant levels of post-discharge morbidity, extending theburden on them and the services requiredto support them for longer than may havebeen previously anticipated. Nurse-ledfollow-up using an auditabledocumentation template can identify theincidence of complications followingdischarge, providing both data to informservice improvement and valuablesupport for patients.

Figure 1: Post-operative morbidity post colorectal resection at 30 days following discharge from hospital

Findings revealed unexpectedly highlevels of post-discharge morbidity in thefollowing areas (figure 1): 35% (n=32) of infection-free

inpatients developed SSI followingdischarge (n=29 elective surgery).

34% (n=47) of all patients had one ormore significant urinary problem(UTI, incontinence, sensory change,hesitancy, frequency, urgency, self-retaining catheter).

Questions regarding dietary intakerevealed an appetite of half, or lessthan half, usual intake in 27% ofpatients (n=37), with moderate tomajor changes in dietary intake in17% (n=17) of people without anileostomy compared to their pre-operative diet.

Of those without an ileostomy, 20%(n=20) had four or more daily bowelmovements, with 22% (n=23)describing their stool consistency aswatery, loose or unsettled. 50%(n=39) of those without a stomareported one or more problematicnew bowel symptom related to theirsurgical experience at 30 days post-discharge (urgency, incompleteemptying, constipation, diarrhoea,tenesmus, excessive wind,incontinence, pain).

Table 1: Description of SampleAgeGender

MaleFemale

PresentationElectiveUrgent/Emergency

StomaIleostomyColostomy

DiagnosisMalignantBenign

Operation SiteLeft-sidedRight-sided

Mean 67.39y (SD 13.692)

n=73 (51.4%)n=69 (48.6%)

n=98 (69%)n=44 (31%)

n=38 (26.8%)n=22 (15.5%)

n=87 (61.3%)n=55 (38.7%)

n=91 (64%)n=51 (36%)