Hospital stays after laparoscopic surgery for colorectal cancer tend to be much shorter than those after conventional open surgery. Many factors, including surgical outcomes and complications, are associated with patient discharge planning. However, few studies have analyzed the impact of patient subjective discomfort (including pain and fatigue) on the decision to discharge after surgery. Therefore, the purpose of this study was to determine how patient pain and fatigue play a role in the decision to discharge after laparoscopic surgery for colorectal cancer.
Between March 2014 and February 2015, we conducted a questionnaire survey of 91 patients who underwent laparoscopic surgery for colorectal cancer to estimate the expectation criteria for discharge and patient subjective discomfort at that time. Patients were divided into the following 2 groups: group A, those who complied with the medical professional’s decision to discharge; and group B, those who refused discharge despite the medical professional’s decision. The participants’ subjective factors were analyzed.
Preoperatively, 78 of 91 patients (85.7%) identified activity level, amount of food (tolerance), and bowel movements as important factors that should be considered in the decision to discharge a patient postoperatively. Postoperatively, 17 patients (18.7%) refused discharge despite a discharge recommendation. Subjective pain and fatigue were significantly different in linear-by-linear association between the group of patients who agreed to be discharge and those who disagreed. Despite this difference, there was no significant difference in mean length of hospital stay between the 2 groups.
A patient’s subjective feelings of pain and fatigue can impact their decision regarding hospital discharge.
Many randomized controlled trials have demonstrated that laparoscopic colorectal surgery produces better short-term outcomes, including less postoperative pain, faster recovery, shorter hospital stays, and earlier return to social activity, than does conventional open surgery [
The purpose of this study was to estimate patients’ expectation criteria for discharge after laparoscopic surgery for colorectal cancer. We used a questionnaire to investigate the subjective factors that might affect patient satisfaction and decisions regarding discharge postoperatively.
Between March 2014 and February 2015, written informed consent was obtained from all participating patients who underwent laparoscopic colorectal cancer surgery at Incheon St. Mary’s Hospital. This study was approved by Institutional Review Board (IRB) of Incheon St. Mary’s Hospital (OC14QISI0007).
After consent was obtained, a 3-part questionnaire was completed by these patients. Part 1 of the questionnaire addressed patient demographics of sex, age, educational level, marital status, presence of a cohabitant, religion, occupation, income level, house structure, existence of private insurance, and presence of caregiver after discharge. Part 2 addressed patients’ expectation criteria for discharge, as follows: amount of food, number of bowel movements until discharge, degree of pain, degree of activity, and self-efficiency. Part 3 focused on the degree of subjective discomfort at the time of discharge, as follows: amounts of food, nausea, or vomiting; discomfort due to changes in bowel habits; pain; effects on activities of daily living; degree of gait; need for caregiver; and fatigue. The patients were asked to complete parts 1 and 2 of the questionnaire preoperatively, while part 3 was administered after the decision regarding discharge. Patient satisfaction and discomfort were assessed using a Likert scale of strongly disagree, disagree, neutral, agree, or strongly agree.
Before surgery, medical professionals explained the overall treatment plan and timetable to patients. A diagram of the treatment plan and timetable was attached to the patient’s bed to help the patient and their caregivers understand the recovery process after surgery (
Mechanical bowel preparation was performed using Colyte (Colyte-F powder, Tae Joon Pharm., Seoul, Korea) 2 days before surgery. Water and carbohydrate drinks (No-NPO, Newcare, Daesang Wellife, Seoul, Korea) were allowed until two hours before surgery.
A nasogastric tube was not inserted. A urinary catheter was inserted soon after general anesthesia was induced and was removed one day after surgery. Patients were allowed to drink water and eat a soft diet starting on the first postoperative day after colon surgery and on the third postoperative day after rectal surgery. The drain was removed 3–5 days after surgery depending on medical situation. The Department of Nutrition provided patents with dietary education during hospitalization. If there were no (suspected) surgical complications and the physical examination and laboratory tests were stable postoperatively, discharge was recommended.
The patients were divided into the following 2 groups: (1) group A, those who complied with the medical professional’s decision to discharge; and (2) group B, those who refused discharge despite the medical professional’s decision. The factors affecting patient discharge were analyzed.
Statistical analysis was performed using independent t-test, chi-square test, and linear by linear association. Statistical significance was considered at a P-value <0.05.
A total of 91 patients completed the questionnaire during the study period. Their mean age was 60.1 years. The male to female ratio was 1.27:1. Fifty-three cases (58.2%) were colon cancer, while 38 (41.7%) were rectal cancer. The mean length of postoperative hospital stay was 6.8 days. Twenty-five patients (27.5%) did not have a spouse, and 16 patients (17.6%) lived alone. Twenty-one patients (23.1%) did not have a caregiver after discharge. Although the government medical insurance covers the entire Korean population, 44 patients (48.4%) also had private medical insurance (
In part 2 of the preoperative questionnaire, 16 patients (17.6%) answered that expected to be discharged when they could eat more than 2/3 of a meal. In contrast, 35 patients (38.5%) replied that the amount of food would not affect the discharge decision. With regard to bowel activity, 54 patients (59.4%) preferred to have one or more postoperative bowel movements before discharge, while 19 patients (20.9%) did not consider this an important factor for discharge. In terms of pain, 52 patients (57.1%) wanted visual analogue scale (VAS) score <2, while 22 (24.2%) wanted VAS score <4 prior to discharge. Finally, 9 patients (9.9%) answered that degree of pain would not affect their discharge decision. Twenty-seven patients (30%) answered that they expected to be discharged when they assumed full activity, while 46 patients (50.5%) considered partial activity sufficient for discharge (
The mean hospital stay after surgery was 6.8 days. When discharge was recommended by medical professionals, 17 patients (18.7%) refused for the following reasons: subjective abdominal pain or discomfort (9 cases); absence of a caregiver at home (3 cases); a long distance between the hospital and home (4 cases); and voiding discomfort (1 case). We divided patients into 2 groups, which were comparable with regard to baseline characteristics (
Postoperatively (based on questionnaire part 3), there were no significant differences between the groups with regard to patient diet satisfaction, subjective gastrointestinal symptoms, or subjective activities of daily living. However, when a linear-versus-linear association was compared, there were significant differences between the group with regard to subjective pain (P = 0.040), ability to walk for a prolonged period (P = 0.005), and presence of fatigue (P = 0.031) (
The combination of minimally invasive surgery and well-organized postoperative management program is important to reduce hospital stay [
In this study, we used the Likert scale in a questionnaire to estimate subjective needs, expectations, and patient satisfaction. The Likert scale has been used in many previous studies and produces comparable results to those of the VAS scale and patient status measurements [
We also investigated patient preoperative needs. Although preoperative counseling is thought to reduce hospital length of stay [
Seventeen patients (18.7%) in this study refused the medical profession’s discharge recommendation. Patients who refused this recommendation had significant differences in subjective pain and fatigue compared to those who accepted the medical profession’s discharge recommendation. Practically, there were no objective complications or abnormalities in laboratory findings of patients in group B. Therefore, both objective medical findings and subjective patient symptoms are essential with regard to timing of discharge after surgery. Many studies have not only investigated the relationship between pain control and number of hospital days after surgery, but also have described several methods to reduce postoperative pain [
In this study, despite no objective medical abnormalities (including VAS, laboratory findings, and complications), some patients were still uncomfortable or experienced fatigue and therefore declined to be discharged. Postoperative fatigue is considered an important complication after surgery. The risk of postoperative fatigue is higher in patients who are elderly, have low nutritional status, or who have undergone gastrectomy. Laparoscopic surgery may reduce the incidence of postoperative fatigue [
There were 17 people in the study who refused to be discharged despite the absence of any postoperative complications. However, discharge was recommended based on objective medical values, without considering subjective patient symptoms. However, this strategy did not meet the patients’ expectation criteria for discharge.
In general, factors that influence length of hospital stay after surgery include surgical factors such as surgical complications and objective factors such as age, American Society of Anesthesiologists physical status classification grade, and patient frailty [
This study has several limitations. First, it was a single-center experience with a small sample size. Therefore, the study was unable to accurately measure a patient’s subjective symptoms. Therefore, a larger, multicenter study is needed to substantiate our findings.
In conclusion, preoperatively, patients considered presence of a bowel movement, amount of food tolerated, and activity level as the most important factors to determine discharge. Patients who refused discharge were more likely to have subjective pain and fatigue than were those who accepted plans for discharge. Therefore, decisions regarding discharge must not only consider the objective medical factors, but also subjective patient factors.
No potential conflict of interest relevant to this article was reported.
Treatment plan and timetable. OP, operation; POD, postoperative day; NPO, none per-oral; PO, per-oral.
Important patient factors for discharge.
Baseline patient characteristics
Variable | No. (%) |
---|---|
Sex | |
Male | 51 (56) |
Female | 40 (44) |
Age (yr) | |
<60 | 36 (39.5) |
≥60 | 55 (60.5) |
Education level | |
High school graduate or less | 74 (81.3) |
College or higher | 17 (18.7) |
Spouse | |
Yes | 66 (72.5) |
No | 25 (27.5) |
Cohabitant | |
Yes | 75 (82.4) |
No | 16 (17.6) |
Religion | |
Yes | 49 (53.8) |
No | 42 (46.2) |
Job | |
Yes | 49 (53.8) |
No | 42 (46.2) |
Income level/mo | |
<3 million KRW | 69 (75.8) |
≥3 million KRW | 22 (24.2) |
Private insurance | |
Yes | 44 (48.4) |
No | 47 (51.6) |
Caregiver | |
Yes | 70 (76.9) |
No | 21 (23.1) |
KRW, Korean won.
Patient preferences at discharge
Patient preferences | No. (%) |
---|---|
Amount of food intake | |
Does not matter | 35 (38.5) |
One-half of typical food intake | 21 (23.1) |
Two-thirds of typical food intake | 13 (14.3) |
Full tolerance of typical food intake | 3 (3.3) |
Postoperative bowel movements | |
>3 | 13 (14.3) |
1–2 | 41 (45.1) |
Flatulence | 18 (19.8) |
Does not matter | 19 (20.9) |
Degree of pain (point) | |
<VAS 2 | 52 (57.1) |
<VAS 4 | 22 (24.2) |
<VAS 6 | 8 (8.8) |
Does not matter | 9 (9.9) |
Activity level | |
Fully active | 27 (29.7) |
Partially active | 46 (50.5) |
Does not matter | 18 (19.8) |
VAS, visual analogue scale.
Baseline characteristics by group
Variable | Group A (n = 74) | Group B (n = 17) | P-value |
---|---|---|---|
Education level | |||
<High school | 59 (79.7) | 15 (88.2) | 0.417 |
≥College | 15 (20.3) | 2 (11.8) | |
Spouse | |||
Yes | 54 (73) | 12 (70.6) | 0.843 |
No | 20 (27) | 5 (29.4) | |
Cohabitant | |||
Yes | 61 (82.4) | 14 (82.4) | 1.000 |
No | 13 (17.6) | 3 (17.6) | |
Religion | |||
Yes | 41 (55.4) | 8 (47.1) | 0.534 |
No | 33 (44.6) | 9 (52.9) | |
Job | |||
Yes | 40 (54.1) | 9 (52.9) | 0.934 |
No | 34 (45.9) | 8 (47.1) | |
Income/mo | |||
<3 million KRW | 59 (79.7) | 10 (58.8) | 0.069 |
≥3 million KRW | 15 (20.3) | 7 (41.2) | |
Private insurance | |||
Yes | 33 (44.6) | 11 (64.7) | 0.135 |
No | 41 (55.4) | 6 (35.3) | |
Caregiver | |||
Yes | 56 (75.7) | 14 (82.4) | 0.753 |
No | 18 (24.3) | 3 (17.6) |
Values are presented as number (%).
Group A, patients who complied with the medical professional’s decision to discharge; group B, patients who refused discharge despite the medical professional’s decision; KRW, Korean won.
Characteristics of the groups by decision regarding discharge
Variable | Group A (n = 74) | Group B (n = 17) | P-value |
---|---|---|---|
Age (yr) | 60.8 ± 11.7 | 57.6 ± 9.1 | 0.365 |
Sex | |||
Male | 45 (60.8) | 6 (35.3) | 0.056 |
Female | 29 (39.2) | 11 (64.7) | |
ASA PS classification | |||
I | 33 (44.6) | 8 (47.1) | 0.962 |
II | 39 (52.7) | 8 (47.1) | |
III | 2 (2.7) | 1 (5.9) | |
Tumor location | |||
Colon | 41 (55.4) | 12 (70.6) | 0.252 |
Rectum | 33 (44.6) | 5 (29.4) | |
Tumor size (cm) | 4.3 ± 2.2 | 3.3 ± 1.6 | 0.134 |
No. of harvested lymph nodes | 21.9 ± 13.2 | 23.2 ± 12.2 | 0.631 |
Distal resection margin (cm) | 7.1 ± 4.4 | 9.4 ± 8.6 | 0.103 |
Proximal resection margin (cm) | 16.7 ± 10.6 | 17.7 ± 12.6 | 0.440 |
TNM stage | |||
1 | 12 (16.2) | 4 (23.5) | 0.748 |
2 | 26 (35.1) | 6 (35.3) | |
3 | 28 (37.8) | 4 (23.5) | |
4 | 8 (10.8) | 3 (17.6) | |
Operative time (min) | 135.6 ± 49.7 | 135.3 ± 43.4 | 0.454 |
Intraoperative blood loss (mL) | 60.4 ± 58.8 | 92.1± 110.7 | 0.003 |
Diet initiation (postoperative day) | 2.6 ± 0.6 | 2.4 ± 0.5 | 0.394 |
Postoperative complications | 0.489 | ||
Yes | 12 (16.2) | 4 (23.5) | |
No | 62 (83.8) | 13 (76.5) | |
Clavien-Dindo classification grade | |||
I | 3 (25) | 2 (50) | |
II | 5 (41.7) | 2 (50) | |
III | 4 (33.3) | 0 (0) | |
Hospital stay (day) | 6.68 (6–23) | 7.35 (6–18) | 0.316 |
Readmission | 5 (6.8) | 2 (11.8) | 0.611 |
Values are presented as mean ± standard deviation, number (%), or mean (range).
Group A, patients who complied with the medical professional’s decision to discharge; group B, patients who refused discharge despite the medical professional’s decision; ASA PS, American Society of Anesthesiologists physical status.
Subjective discomfort by group
Question | Group A (n = 74) | Group B (n = 17) | P-value |
---|---|---|---|
I am satisfied with my current diet after surgery. | 0.486 | ||
1 | 0 (0) | 0 (0) | |
2 | 6 (8.1) | 0 (0) | |
3 | 10 (13.5) | 3 (17.6) | |
4 | 45 (60.8) | 10 (58.6) | |
5 | 13 (17.6) | 4 (23.5) | |
I currently have nausea or vomiting. | 0.115 | ||
1 | 31 (41.9) | 10 (58.8) | |
2 | 35 (47.3) | 7 (41.2) | |
3 | 7 (9.5) | 0 (0) | |
4 | 1 (1.4) | 0 (0) | |
5 | 0 (0) | 0 (0) | |
I am uncomfortable with changes in bowel habits after surgery. | 0.614 | ||
1 | 8 (10.8) | 3 (17.6) | |
2 | 30 (40.5) | 6 (35.3) | |
3 | 15 (20.3) | 4 (23.5) | |
4 | 19 (25.7) | 4 (23.5) | |
5 | 2 (2.7) | 0 (0) | |
I am able to tolerate pain after surgery. | 0.040 | ||
1 | 1 (1.4) | 1 (5.9) | |
2 | 5 (6.8) | 1 (5.9) | |
3 | 11 (14.9) | 6 (35.3) | |
4 | 44 (59.5) | 9 (52.9) | |
I find it difficult to walk for long distances. | 0.005 | ||
1 | 10 (13.5) | 2 (11.8) | |
2 | 40 (54.1) | 3 (17.6) | |
3 | 13 (17.6) | 6 (35.3) | |
4 | 11 (14.9) | 5 (29.4) | |
5 | 0 (0) | 1 (5.9) | |
I need help from someone at home. | 0.056 | ||
1 | 10 (13.5) | 2 (11.8) | |
2 | 45 (60.8) | 6 (35.3) | |
3 | 6 (8.1) | 3 (17.6) | |
4 | 13 (17.6) | 5 (29.4) | |
5 | 0 (0) | 1 (5.9) | |
I am easily fatigued. | 0.031 | ||
1 | 6 (8.1) | 1 (5.9) | |
2 | 26 (35.1) | 2 (11.8) | |
3 | 23 (31.1) | 4 (23.5) | |
4 | 17 (23) | 10 (58.8) | |
5 | 2 (2.7) | 0 (0) |
Values are presented as number (%).
Point: 1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree.
Group A, patients who complied with the medical professional’s decision to discharge; group B, patients who refused discharge despite the medical professional’s decision.