“FASTRACK” PROTOCOLS IMPROVE OUTCOME FOR
COLORECTAL SURGERY
Anthony J. Senagore, MD,MS.
Krause-Lieberman Chair in Laparoscopic Colorectal Surgery
Department of Colorectal Surgery
Cleveland Clinic Foundation, 9500 Euclid Avenue, A-30
Cleveland, Ohio 44195, USA
email: senagoa@ccf.org
Introduction
Ttraditionally, postoperative stay following major gastrointestinal surgery has been between
five and ten days, with recent Medicare data revealing a mean length of stay of 11.3 days for DRG
148. The emphasis on reducing resource utilization brought about by transitions in payment for
medical services, coupled with improved understanding of perioperative
physiology have
significantly reduced the hospitalization after colectomy. A further pressure reducing length of stay
after colectomy has been the greater use of minimally invasive surgical techniques which have been
associated with postoperative stays of 2.1 to 4.5 days. . .
A variety of factors contribute to the length of stay including inadequate analgesia, nausea
and vomiting, delay in ileus resolution, and stress-induced organ dysfunction. In addition, iatrogenic
factors including use of nasogastric tubes, transabdominal drains, and enforced malnutrition and bed
rest all adversely affect patient recovery after colectomy. Kehlet et al have recently attempted to
employ a multimodal rehabilitation program aimed at reducing both the physiologic and iatrogenic
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factors delaying post-operative recovery. The key components of this program are routine use of
thoracic epidural anesthesia and analgesia with local anesthetics, and early feeding coupled with the
use of cathartics. Using this approach they were able to produce a median postoperative stay of two
days after elective sigmoid colectomy in an initial group of 18 patients. These results were
maintained in a larger cohort of 60 patients, who demonstrated a median stay of two days, and
included 32 patients discharged within 48 hours. A number of authors have described perioperative
care plans, although not routinely using pre-emptive epidural analgesia and oral cathartics. These
plans have consistently reduced length of stay, however they have been associated with relatively
high early readmission rates of 9-11%. In addition, many of the protocols have altered discharge
criteria from typically accepted thresholds by allowing discharge on clear liquids without any
evidence of return of bowel function. Finally, these pathways are generally reserved for patients
undergoing relatively straightforward, uncomplicated colonic resections.
We have employed a similar conceptual approach to “fast-track” recovery after colectomy for
both laparoscopic resections and complex re-operative bowel resection and pelvic surgery. A key
component of success in our experience has been to carefully explain the principles of the ‘fast-track’
care to each patient prior to surgery. It is important to describe the daily benchmarks expected for the
patient (including discharge criteria) prior to admission and to reinforce the same message daily. We
avoid the routine use of NG tubes after surgery and limit the use of abdominal drains. Patients are
expected to walk the evening of surgery if at all possible and are ambulated at least 5 times per day
thereafter. The initial meal offered is full liquids followed by advancement to a GI diet as soon as
tolerated. We have not routinely employed epidural analgesia however attempts are made to transfer
all patients to oral narcotic based analgesia regimens supplemented with NSAID’s within 24 hours.
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We have evaluated this protocol in 58 complex bowel resection patients with a mean age was
44.4 ± 13.5 years (range 13 to 70). Thirty-four patients had undergone one or more previous major
laparotomies (58.5%), two had undergone minor laparotomies (3.5%; appendicectomy and
cholecystectomy), and 22 had never had a laparotomy (38%). Patients who were classified as being
in DRG 148 (n=40) stayed 4.6 ± 1.7 days, significantly longer than those in DRG 149 (n=18) who
stayed only 3.5 ± 0.8 days (p=0.01). The presence of a defunctioning loop ileostomy, or a history of
previous abdominal surgery did not affect time to discharge. Hospital stay was longer in 8 eight
patients who complied poorly with the fastrack protocol (from 4.3 to 5.1 days, p=0.02). There were 4
readmissions within 30 days postoperatively, although none were due to GI failure. We subsequently
evaluated the historical length of stay at our institution for patients in DRG 148 and 149 has shown a
slight reduction for the year 1999, when compared to the decade from 1991 to 1999 (148: 8.4 vs 9.6
days; 149: 6.4 vs 4.3 days). Utilization of the same care plan for laparsocopic colectomy patients has
yielded a mean length of stay of 2.4 days.
Our work has identified several issues related to the use and efficacy of these protocols. We
believe that the ‘fastrack’ approach is applicable to the large majority of cases undergoing colorectal
surgery. However, in contrast to the findings of Basse and colleagues who found that patients do
equally well, whatever their status of co-morbidity, we have determined that patients without comorbidity do even better than those with co-morbidity and can achieve hospital stays of only 3.5 ±
0.8 days. This is not affected by prior abdominal surgery and confirms that these clinical pathways
should be available to all cohorts of colectomy and pelvic surgery patients.
The benefits of early discharge have been variously argued in the literature, with some
suggesting only marginal cost savings due to the difference in resource consumption early in the
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perioperative period. This contention, however assumes that the institution is under no constraints
related to hospital occupancy or access to nursing services. Neither is the case at our institution
where hospital census routinely runs above 95% and there is a severe nursing shortage in the region.
Thus the benefit of safe early discharge allows us to admit another patient for surgery which
improves patient access as well as providing financial benefit to the institution. . Indeed, as Taheri
and colleagues have themselves previously argued, the payments received for these patients can be
thought of as pure profit (apart from direct expenses), because staff and institutional costs have been
paid already (17).
Our experience with these protocols for both open and laparoscopic colectomy have lead to
several conclusions. First, the use of a ‘fastrack’ protocol is well tolerated by all patient cohorts
regardless of co-morbidity or complexity of procedure. Second, the protocol permits rapid recovery
and early discharge from hospital, without adverse events related to the accelerated nature of the
postoperative care. Third, the approach is enthusiastically embraced by the educated patients. The
ability of the modern abdominal surgeon to embrace these concepts of enhanced recovery after
surgery has the potential of allowing patients to be discharged significantly earlier from hospital,
reducing rates of nosocomial infection, allowing more efficient use of hospital beds and reducing
hospital costs.
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