Application of a Fast Track Protocol for Colorectal Surgery in a Community Hospital

Abraham Fridman, DO, Sharon B Larson, DO, Sampath Kumar, MD, Frank Lacqua, MD, Pratap Gadangi, MD, George Ferzli, MD. Lutheran Medical Center, Dept of Surgery, Brooklyn, NY

INTRODUCTION/OBJECTIVE: A fast track protocol for colorectal surgery patients has been described in many recent studies. Most of the studies are from large university based institutions with a large volume of patients. The results have shown that this protocol decreases the hospital stay without increase in adverse events. There are no papers that describe the application of this protocol at a community hospital. In this study we will try to assess whether a fast track protocol can be applied at a community hospital in Brooklyn, New York.

METHODS AND PROCEDURES: We conducted a prospective, non-randomized trial, evaluating all patients presenting in ambulatory surgery undergoing colorectal surgery at our institution. Only patients undergoing elective procedures involving any colon or rectum resections were included. All the subjects were followed while in the hospital and then again if they had any re-admissions after discharge. The only exclusion criteria used was emergency colorectal surgery cases. It was left to the discretion of the attending surgeon whether the fast track protocol would be applied to their patients. Goals of the protocol included the following:
Pre-operative oral intake of fluids and no bowel preparation, Post-operative early mobilization out of bed, no routine use of nasogastric tubing, utilization of multimodal analgesia, the use of prokinetics such as Metoclopramide, enforced introduction of clear liquid diet post-operative day 1, and early removal of bladder catheter.

RESULTS: We had 31 patients undergo colorectal resection over a 5-month period with 6 patients completing the fast track protocol. Laparoscopic resection was used in 5 cases and 3 completed the protocol. Open resection was used in 26 cases and 3 completed the protocol. Left colon resections were performed in 23 patients and 4 completed the protocol. Right colon resections were performed in 7 patients and 2 completed the protocol. Subtotal colectomy was performed in 1 patient and that patient did not complete the protocol. General surgeons operated in 19 cases with 2 patients completing the protocol. Colorectal surgeons operated in 12 cases with 4 completing the protocol. Average length of hospital stay was 6.68 days with a range of 2-22 days. Readmission occurred in 2 cases for intra-abdominal abscess formation. Mortality occurred in 2 cases due to myocardial infarction leading to cardiac arrest.

CONCLUSION: A fast track protocol for elective colon resection is not applicable in a community hospital setting. Those patients who completed the fast track protocol were more likely to have had laparoscopic resections of the right colon performed by colorectal surgeons. The greatest obstacle to adherence of a fast track protocol in a community hospital setting is overcoming anecdotal preferences for peri-operative management after elective colon resection.