title: Timing of complications and length of stay after rectal cancer surgery.
abstract: BACKGROUND
  Enhanced recovery pathways have been shown to improve short-term outcomes after colorectal surgery. Occurrence of complications can lead to prolonged length of stay (LOS). The goal of this study was to examine whether shorter time to occurrence of complications was associated with a shorter hospital LOS in rectal cancer patients undergoing minimally invasive surgery, taking into account the perioperative pathway.
  
  
  METHODS
  This retrospective study included consecutive patients undergoing rectal cancer resection from 2005 to 2011 at a single institution. Enhanced recovery pathway was introduced in 2009. Complications and date of occurrence were reviewed. The impact of perioperative care modalities and comorbidities was evaluated using competing risk models with occurrence of complications and LOS as time-dependent outcomes measured as time from surgery.
  
  
  RESULTS
  A total of 346 patients were included in the analysis with 78 patients treated with enhanced recovery pathway, and 268 with established care. The overall complication rate was 22.3% (77 patients with ileus, wound infection, leak, abscess, small bowel obstruction, reoperation for bleeding, and renal failure). Median time to occurrence of a complication was 3 days post operation. The time to complication diagnosis was associated with shorter time to discharge after the advent of the complication (hazard ratio = 0.84; 95% CI, 0.73-0.96; p = 0.01). Enhanced recovery pathway was associated with a shorter LOS for patients without complications compared with the established pathway (hazard ratio = 2.81; 95% CI, 2.09-3.78; p < 0.001) after adjusting for comorbidities in a competing risk model.
  
  
  CONCLUSIONS
  Early diagnosis of postoperative complications is associated with a shorter LOS after rectal cancer surgery. Enhanced recovery pathway can facilitate a faster recovery in the presence of comorbidities.
authors.affiliation: Department of Statistics and Probability, Michigan State University, East Lansing, MI; Department of Health Sciences Research, Mayo Clinic, Rochester, MN. Electronic address: huebner@stt.msu.edu.
authors.forename: Marianne
authors.initials: M
authors.lastname: Huebner
authors.affiliation: Clinic for Visceral Surgery, University of Lausanne, Switzerland.
authors.forename: Martin
authors.initials: M
authors.lastname: Hübner
authors.affiliation: Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
authors.forename: Robert R
authors.initials: RR
authors.lastname: Cima
authors.affiliation: Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN.
authors.forename: David W
authors.initials: DW
authors.lastname: Larson
mesh_terms: D003082:Colectomy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007902:Length of Stay / Q000639:trends*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology*; D011379:Prognosis; D012004:Rectal Neoplasms / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology