Abstract
Purpose
This single-center prospective cohort study, conducted outside of a clinical trial, tried to identify the importance of each fast-track surgery procedure and protocol adherence level on clinical outcomes after colorectal surgery.
Methods
From a prospectively maintained database, 606 patients who underwent elective laparoscopic or open colorectal resection within a well established fast-track surgery (FT) protocol, between 2005 and 2011, were identified. Univariate and multivariate analysis were performed to assess the relationship between each FT procedure with an adherence rate <100 % and the outcome variables (length of stay—LOS, 30-day morbidity and readmission rate). Patients were divided into four adherence level groups to FT procedures—100 %, 85–95 %,70–80 %, and <65 %. Each adherence group was compared with the other groups to evaluate differences in clinical outcome variables.
Results
Group comparisons revealed that higher levels of FT protocol adherence corresponded to significantly improved LOS and morbidity rates. Readmission rates were only significantly different between the full fast-track pathway and the less implemented groups. Multivariate analyses revealed that the fast removal of bladder catheter positively influenced length of stay (p < 0.0001) and 30-day morbidity (p < 0.0001). Laparoscopy surgery, no drain positioning and enforced mobilization improved LOS (p = 0.027, p < 0.0001, p = 0.002, respectively). Early solid feeding improved LOS (p < 0.0001), morbidity (p < 0.0001) and readmission rate (p = 0.011).
Conclusion
Postoperative outcomes after colorectal surgery are directly proportional to FT protocol adherence. The early removal of the bladder catheter and early postoperative solid feeding independently influenced the length of hospital stay and 30-day morbidity rates.
Similar content being viewed by others
Reference
Slim K (2011) Fast-track surgery: the next revolution in surgical care following laparoscopy. Colorectal Dis 13(5):478–480
Lassen K, Soop M, Nygren J, Cox PB, Hendry PO, Spies C, von Meyenfeldt MF, Fearon KC, Revhaug A, Norderval S, Ljungqvist O, Lobo DN, Dejong CH, Enhanced Recovery After Surgery (ERAS) Group (2009) Consensus review of optimal perioperative care in colorectal surgery: Enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144(10):961–969
Raue W, Haase O, Junghans T, Scharfenberg M, Muller JM, Schwenk W (2004) ‘Fast-track’ multimodal rehabilitation program improves outcome after laparoscopic sigmoidectomy: a controlled prospective evaluation. Surg Endosc 18:1463–8.45
Basse L, Jakobsen DH, Bardram (2005) Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Ann Surg 241:416–423
King PM, Blazeby JM, Ewings P (2006) The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer. Colorectal Dis 8:506–513
Basse L, Thorbol JE, Lossl K, Kehlet H (2004) Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 47:271–277
Gatt M, Anderson AD, Reddy BS, Hayward-Sampson P, Tring IC, MacFie J (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 92:1354–1362
Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA (2007) A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 245:867–872
Muller S, Zalunardo MP, Hubner M, Clavien PA, Demartines N (2009) A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 136:842–847
Serclova Z, Dytrych P, Marvan J et al (2009) Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Clin Nutr 28:618–624
Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW (2003) Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 46:851–859
Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90:1497–1504
Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ (2011) Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. Feb 16(2):
Maessen J, Dejong CH, Hausel J, Nygren J, Lassen K, Anderson J (2007) A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 94:224–231
Ahmed J, Khan S, Gatt M, Kallam R, MacFie J (2010) Compliance with enhanced recovery programmes in elective colorectal surgery. Br J Surg 97(5):754–758
Lassen K, Hannemann P, Ljungqvist O, Fearon K, Dejong CH, von Meyenfeldt MF, Hausel J, Nygren J, Andersen J, Revhaug A, Enhanced Recovery After Surgery Group (2005) Patterns in current perioperative practice: survey of colorectal surgeons in five northern European countries. BMJ 330(7505):1420–1421
Fearon KC, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CH, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H (2005) Enhanced recovery aftersurgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24(3):466–477
Feroci F, Kröning KC, Lenzi E, Moraldi L, Cantafio S, Scatizzi M (2011) Laparoscopy within a fast-track program enhances the short-term results after elective surgery for resectable colorectal cancer. Surg Endosc 25(9):2919–2925
Scatizzi M, Kröning KC, Boddi V, De Prizio M, Feroci F (2010) Fast-track surgery after laparoscopic colorectal surgery: is it feasible in a general surgery unit? Surgery 147(2):219–226
Gustafsson UO, Hausel J, Thorell A, Ljungqvist O, Soop M, Nygren J, Enhanced Recovery After Surgery Study Group (2011) Adherence to the enhanced recovery after surgery protocol and outcomes after colorectal cancer surgery. Arch Surg 146(5):571–577
Vlug MS, Wind J, Wind J, van der Zaag E, Ubbink DT, Cense HA, Bemelman WA (2009) Systematic review of laparoscopic versus open colonic surgery within an enhanced recovery programme. Colorectal Dis 11:335–343
Polle SW, Wind J, Fuhring JW, Hofland J, Gouma DJ, Bemelman WA (2007) Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 24:441–449
Soop M, Nygren J, Ljungqvist O (2006) Optimizing perioperative management of patients undergoing colorectal surgery: what is new? Curr Opin Crit Care 12:166–170
Walter CJ, Smith A, Guillou P (2006) Perceptions of the application of fast-track surgical principles by generalsurgeons. Ann R Coll Surg Engl 88:191–195
Kahokehr A, Sammour T, Zargar-Shoshtari K, Thompson LG, Hill AG (2009) Implementation of ERAS and how to overcome the barriers. Int J Surg 7:16–19
Hendry PO, Hausel J, Nygren J, Lassen K, Dejong CH, Ljungqvist O, Fearon KC, Enhanced Recovery After Surgery Study Group (2009) Determinants of outcome after colorectal resection within an enhanced recovery programme. Br J Surg 96(2):197–205
Adamina M, Kehlet H, Tomlinson GA, Senagore AJ, Delaney CP (2011) Enhanced recovery pathways optimize health outcomes and resource utilization: a meta-analysis of randomized controlled trials in colorectal surgery. Surgery 149(6):830–840
Vlug MS, Wind J, Hollmann MW, Ubbink DT, Cense HA, Engel AF, Gerhards MF, van Wagensveld BA, van der Zaag ES, van Geloven AA, Sprangers MA, Cuesta MA, Bemelman WA, LAFA study group (2011) Laparoscopy in combination with fast track multimodal management is the best perioperative strategy in patients undergoing colonic surgery: a randomized clinical Trial (LAFA-study). Ann Surg 254(6):868–875
Basse L, Werner M, Kehlet H (2000) Is urinary drainage necessary during continuous epidural analgesia after colonic resection? Reg Anesth Pain Med 25(5):498–501
Andersen HK, Lewis SJ, Thomas S (2006) Early enteral nutrition within 24 h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev. CD004080
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Feroci, F., Lenzi, E., Baraghini, M. et al. Fast-track colorectal surgery: protocol adherence influences postoperative outcomes. Int J Colorectal Dis 28, 103–109 (2013). https://doi.org/10.1007/s00384-012-1569-5
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-012-1569-5