Authors (including presenting author) :
Chan PT, Fung TL, Kwok KH
Affiliation :
Department of Surgery, Queen Elizabeth Hospital
Introduction :
Endoscopic submucosal dissection (ESD) is a highly technically demanding procedure. It allows enbloc resection of neoplastic lesions through endoscopic means without the need of major operation. Comparing with traditional colectomy, the advantages of ESD, which include shorter hospital stay, readmission rate and complication rate, are also proven in our previous QEH study. With the population colorectal cancer screening programms, the number of colorectal neoplastic lesions is increasing, and so as the demand for the colorectal ESD services.
Objectives :
Our colorectal ESD service has been strived for continuous quality improvement in recent years. Since its a very technically demanding procedure, to provide a high quality service, numerous methods are introduced to improve service efficacy and to enhance patients' safety. Our Aim is to 1)Decrease the length of hospital stay 2)improve surgical outcome and enhance patients safety 3)Maximize the use of resources and cost saving. The measures being used were 1. Implementation of new Protocol i. Pre-op workup in outpatient setting ii. Promoting Day admission through day ward iii.Early resumption of diet, mobilization and discharge iv. Non-mandatory workup or pre-op procedures are reserved for selected cases only 2. Providing regular simulation training using pig models 3. Increasing number of operation performed per session 4. Using bolus IV sedation by surgeon in endoscopy center instead of MAC/GA in OT theatre
Methodology :
A total number of 271 cases were reviewed from 2015-2020. The length of stay, complication rates, maximal size of lesions successfully en bloc resected ,day ward usage, sedation techniques, pre-op workup venue, number of simulation training , OT sessions saved were reviewed.
Result & Outcome :
< A. Shortened Length of Stay > Reduction of 40% median length of stay from post op D4 (2018) to D2 (2020) after the new protocol < B. Improved surgical outcome and enhanced patient safty > 1. Complication rate in QEH (SUR) is even lower than the international one. Delayed perforation rate 1 % vs 0.36 % (international vs QEH) Delayed bleeding rate 4% vs 0.73% (international vs QEH) 2.High enbloc resection rate and the maximal size of lesion successfully removed increased to 12 cm circumferential lesion. Patient can be saved from a major operation despite such a large size of neoplastic lesion. 3. Regular simulation training models workshop every 2 months and supervised by qualified trainer were arranged since late 2017 to enhance the clinical safety and ensure service quality. < C. Maximize resources and cost saving> 1. All pre-operative workup and assessment in outpatient setting. 2. Admission through Day ward reduced the in-patient ward workload and increase patient capacity during busy morning period. 3. Double the service capacity by doubling the number of operation performed per session. 4. Saving at least 45 OT sessions per year and reducing the cost of service by using bolus IV sedation by surgeons for the procedure in endoscopy center given by surgeons instead of MAC/GA in Operation theatre.
