Editorial

Traditionally, colonic resection with primary anastomosis was associated with a lengthy hospital course. Patients were often admitted to the hospital not only well in advance of the intended operation, but in point of fact, before knowledge of the pathologic findings. Specifically, symptoms led to an inpatient rather than an outpatient assessment by methodology, including sigmoidoscopy and air-contrast barium enema and, subsequently, colonoscopy. These evaluations were performed only after a 3-day starvation regimen, including restriction to a clear-fluid diet and administration of daily purgatives or enemas, or both. Once the diagnosis was made, the patient remained in the hospital for surgery and for a lengthy recovery; 2-week postoperative hospitalizations were quite routine. A variety of external forces, including third-party payers, hospital executives, and the healthcare industry, joined forces with physicians and patients to find better ways of shortening hospital stays while improving, if not at the very least maintaining, the “status quo.” Parties from the former set of forces included the third-party payers and their shareholders who demanded reduced hospital costs. Clearly, shortening the length of hospital stay in both the preoperative and postoperative periods contributed to reduced costs. These benefits were realized as long as costly morbidity and readmission because of such morbidity, or failure of patients to manage in the homecare environment, did not ensue. Parties in the second category included an industry striving to manufacture products conducive to shortened lengths of hospital stay. As an example, Dipalma and Marshal1 described a 4-L polyethylene glycol bowel preparation to replace the traditional 3-day in-hospital regimen. The polyethylene glycol preparation was ultimately touted as satisfactory not only in the in-hospital setting but also as an outpatient bowel preparation allowing “same day” or “morning of surgery” hospital admissions.2,3 More recently, the sodium phosphate preparation has been shown in two separate prospective randomized surgeon-blinded trials of a total of 650 patients to be superior to the 4-L polyethylene glycol preparation.4,5 Specifically, these studies revealed improved patient compliance with the lower volume sodium phosphate preparation because of less trouble drinking the preparation, less abdominal pain, and less bloating. More patients were able to consume the entire preparation, which may have had an impact on the superiority of the lower volume preparation. Importantly, in the colonoscopy trial (n 5 450), whereas 83% of patients said that they would take the sodium phosphate preparation again, only 19% gave that response for the 4-L polyethylene glycol preparation. Similar results were noted in the surgery study (n 5 200); there was no increase in septic morbidity. The preparation can easily be consumed at home, allowing patients surgical preparation in the comfort and confines of their own environment. Although at first glance, patients seemed reluctant to be “pushed out” of the hospital, home health care agencies have become an integral part of the planning, even from the time of admission to hospital. Patients are instructed on expectations for discharge before admission to hospital. The nurse cliniReceived January 16, 1998; Revised February 10, 1998; Accepted February 19, 1998. From the Department of Colorectal Surgery, Cleveland Clinic Florida, Ft. Lauderdale, FL. Correspondence address: Steven D. Wexner, MD, FACS, FASCRS, FACG, Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 W. Cypress Creek Road, Ft. Lauderdale, FL 33309-1743.