Same-day discharge after endoscopic submucosal dissection safe, ‘viable option’
CHARLOTTE, N.C. — Same-day discharge is a safe and feasible option for patients who undergo endoscopic submucosal dissection, according to a presentation at the ACG Annual Scientific Meeting.
“Patients undergoing endoscopic submucosal dissection (ESD) have traditionally been admitted for routine post-procedural observation. In the COVID era, though, beds and staff are often in short supply,” William W. King, MD, an internal medicine resident at University of Florida Health and University of Florida College of Medicine, told Healio. “We had so much data from the multicenter ESD database. Therefore, we sought to perform a post-hoc analysis to understand whether admission is truly necessary or whether patients can safely be discharged the same day.”
The study included 831 adults (median age, 67 years; 57% men) who underwent ESD at 10 participating centers between 2016 and 2021, of whom 240 underwent esophageal ESD, 126 gastric ESD and 465 colorectal ESD. Patients were grouped by those with same-day discharge (SDD; n = 588) and those who were admitted (n = 243).
The primary endpoint was SDD safety and feasibility after ESD, as well as factors linked to hospital admission. Endoscopists who handled fewer than 50 cases were considered low-volume, and lesions were considered to have a depressed morphology component when classified as Paris 0-IIc or III.
King and colleagues reported that 13 patients in the SDD group had delayed bleeding, with nine requiring repeat endoscopy and two requiring a blood transfusion. Delayed perforation was identified in four patients, although only one needed surgery.
Of those admitted to the hospital, 223 (92%) were discharged within 24 hours after routine post-procedural observation. Nineteen of the remaining patients were admitted for bleeding (n = 3) and intraprocedural perforation (n = 16). These adverse events did not require surgery and were managed endoscopically. Patients experienced a mean hospital stay of 1.3 ± 0.8 days.
“A small subset of patients clearly needs to be admitted due to unexpected complications during the procedure,” King said. “However, the vast majority of patients can be safely discharged following the procedure.”
The researchers also reported that lesion size of at least 45 mm inversely correlated with admission based on multivariate analysis (OR = 0.5; 95% CI, 0.3-0.8). Factors independently associated with a greater chance of admission included esophageal or gastric ESD vs. colorectal ESD (OR = 1.7; 95% CI, 1.1-2.6), low endoscopist volume (OR = 2.1; 95% CI, 1.3-3.3), invasive cancer histology at baseline (OR = 1.9; 95% CI, 1.2-3.1), adverse events (OR = 2.7; 95% CI, 1.5-4.8) and procedure time longer than 75 minutes (OR = 13.5; 95% CI, 8.5-21.3).
“As for the patients who are admitted to the hospital despite the absence of complications, we find a wide variation in practices between different endoscopists,” King said. “However, patients who are sicker at baseline and had more complicated procedures were generally more likely to require admission.”
According to King, a randomized study is needed to compare a group of patients planned for routine admission with another group routinely discharged after a successful procedure.
“We suspect that some patients would be admitted, discharged and need to come back. Others would be discharged the same day as the procedure but would need to come back,” King said. “However, we suspect that overall, there would be no difference in health outcomes between the groups.”
This finding, according to King, would save a “tremendous” number of beds and staffing resources at centers where ESD is offered.
“The decision to admit or discharge a patient after the procedure should be an open discussion between a patient and their doctor,” King said. “However, this study should reassure gastroenterologists that routine discharge following ESD is safe and should be considered a viable option if the patient and endoscopist are both comfortable with it.”
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King WW, et al. Abstract S1068: Safety and Feasibility of Same-Day Discharge After Endoscopic Submucosal Dissection in the Upper GI Tract: A Western Multicenter Prospective Cohort Study. Presented at: ACG Annual Scientific Meeting; Oct. 21-26, 2022; Charlotte, N.C. (hybrid meeting).