Factors influencing length of stay after surgery for benign foregut disease

Length of stay (LOS) is an important measure of quality and healthcare costs. Variation occurs due to individual and institutional practices, case complexity and patient/social factors. Identification of variables affecting LOS may help develop enhanced recovery protocols. This study aims to identify factors influencing LOS following surgery for hiatal hernia, gastro-oesophageal reflux and achalasia.

We identified all patients who underwent benign foregut surgery between August 2013 and July 2014 inclusive. Data from a prospectively maintained database were collected and univariate/multivariable analyses were performed. All patients were contacted to determine their 30-day readmission rate to any hospital.

One hundred and sixty-five patients were identified in the 12-month period; 68% underwent laparoscopic surgery and 32% open surgery. The rates of laparoscopic conversion to open surgery and operative mortality were zero. Statistically, the most significant predictor of LOS was the surgical approach. The median LOS was 2 days for laparoscopic surgery and 4 days for open surgery. Beyond the surgical approach, the following factors were significant in predicting LOS: for laparoscopic surgery patients, younger age, shorter operative time, nasogastric (NG) tube removal in the operation theatre (OT), OT exit before noon, low postoperative nausea counts and discharge to home rather than a skilled facility were associated with reduced LOS. For open surgery patients, younger age, American Society of Anesthesiologists grade I-II, urinary catheter removal before discharge, discharge to home and discharge on the weekend were associated with reduced LOS. Whether surgery was primary or reoperation did not affect LOS. The overall 30-day readmission rate was 5% (laparoscopic 3% and open 12%; P = 0.003).

The laparoscopic surgery approach, where feasible, in the treatment of benign foregut diseases is the strongest predictor of a decreased LOS. Modifiable factors influencing LOS include OT exit time, NG tube removal in the OT, urinary catheter removal in hospital and postoperative nausea control. Any implementation of enhanced recovery pathways to optimize these factors must monitor readmission rates and complications to confirm efficacy.