Fast-Track Surgery May Reduce Complications Following Major Colonic Surgery ORIGINAL Kamran Zargar-Shoshtari, M.B.Ch.B.1 CONTRIBUTION Andrew B. Connolly, M.B.Ch.B., F.R.A.C.S.2 Lincoln H. Israel, M.B.Ch.B., F.R.A.C.S.2 Andrew G. Hill, M.D., F.R.A.C.S.1
1 South Auckland Clinical School, University of Auckland, Middlemore Hospital, Auckland, New Zealand 2 Middlemore Hospital, Auckland, New Zealand
PURPOSE: Fast-track (enhanced recovery) care pathways for colonic surgery are becoming increasingly popular; however, there have been concerns regarding protocol compliance, high readmission rates, and also the true impact on morbidity rates with these protocols. This study was conducted to assess the impact of a fast-track program for colonic surgery on hospital stay, complications, and readmission rates. METHODS: From December 2005 to March 2007, consecu-
tive patients undergoing colonic surgery were prospectively studied. The comparison group consisted of a comorbiditymatched group of patients who had undergone similar surgery before establishment of the fast-track program. RESULTS: Fifty patients were included in each group.
Groups were comparable at baseline. The fast-track group received significantly smaller amounts of intraoperative and postoperative intravenous fluids, were fed earlier, mobilized earlier, passed flatus earlier, and were discharged earlier than the comparison group (4 vs. 6.5 days, P<0.001). The numbers of patients with urinary infections (2 vs. 12, P=0.008), ileus (5 vs. 18, P=0.005), and cardiopulmonary complications (11 vs. 21, P=0.032) were significantly lower in the fast-track group. There was no difference in the rate of readmission. CONCLUSION: Fast-track is a safe and effective approach
for reducing hospital stay and morbidity following major colonic surgery. KEY WORDS: Fast-track; Enhanced recovery after surgery;
Colonic surgery; Complications.
D
uring the past decade, various pathways have been developed for fast-track perioperative care after colonic
Presented at the Annual Scientific Congress of the Royal Australasian College of Surgeons, May 6 to 11, 2007, Christchurch, New Zealand This research was conducted during tenure of a Clinical Research Training Fellowship from Health Research Council of New Zealand. Address of correspondence: Andrew G. Hill, South, M.D., Auckland Clinical School, University of Auckland, Middlemore Hospital, Auckland, New Zealand. E-mail:
[email protected]
surgery, also referred to as enhanced recovery after surgery (ERAS). These consist of a number of evidenced-based interventions which individually have been associated with improved outcomes following major surgery. Multimodal use of these strategies aims to reduce surgical stress and hasten return of organ function and hence accelerate recovery following major surgery.1 However, even in centers with long-established ERAS programs, compliance rates with these pathways are problematic. Furthermore, units which have employed identical ERAS protocols have had inconsistent outcomes. This reiterates the many challenges involved in implementing and sustaining such programs.2,3 The majority of the published literature on this topic has focused on reduction of hospital stay as the most significant outcome measure for ERAS programs.3–10 Only one prospective study and a systematic review have shown significant reductions in morbidity rates with these pathways.7,11 In December 2005, we commenced an ERAS program for elective colonic resection within our hospital, Manukau Surgical Centre in Auckland. Our approach emphasizes structured nursing care pathways within an environment that focuses on early recovery, with incorporation of a number of other perioperative strategies within the ERAS framework. The aim of this study was to evaluate the impact of this ERAS program on major patient outcomes, particularly on complications, as well as to assess the extent of protocol compliance within the program.
PATIENTS AND METHODS Patients The study group consisted of consecutive patients enrolled in the ERAS program for elective colonic surgery at Manukau Surgical Centre from December 2005 to March 2007. Patients with significant cardiopulmonary comorbidities (American Society of Anesthesiologists (ASA) score > III) or significant cognitive impairment, or who declined to take part, were not enrolled in the ERAS program. Patients who required a stoma were not considered for the program during the study period because management of a stoma required strategies which were not part of our ERAS protocols.
DOI: 10.1007/s10350-008-9386-1 VOLUME 51: 1633–1640 (2008) ©THE ASCRS 2008 PUBLISHED ONLINE: 7 JUNE 2008
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The study group was compared with a group of matched historical controls consisting of a comparable, consecutive series of patients identified through an electronic database search for patients treated at our institution from September 2004 to September 2005 (before the start of the ERAS program) who met the criteria used for the ERAS program and had undergone elective colonic surgery performed by the same surgeons who treated the patients in the ERAS group. Patients in the control group received conventional, nonstructured perioperative care, and discharge was left to the discretion of the senior members of the team with no specified discharge criteria in place. As far as possible, control patients were matched with those in the ERAS group with respect to ASA score, CR-POSSUM (Colorectal Physiological and Operative Severity Score for the enUmeration of Mortality), and operation type. CR-POSSUM is a sixfactor physiologic score plus a four-factor operative severity score that has been validated as a practical tool for prediction of postoperative mortality.12 Data were collected from patients’ clinical records, including all clinical, radiologic, and laboratory results from the preoperative period to 30 days after surgery. To ensure that recorded complications were comparable in both groups, specific complications were defined according to the criteria shown in Table 1. Furthermore, to prevent overestimation of complications in the retrospective control group, only well-documented events that required specific interventions were included.
Table 1. Definition of perioperative complications
Complication Ileus
Urinary tract infection Wound Chest infection
Fluid overload Cardiac Urinary retention Anastomotic leak
Criteria No flatus, abdominal distension nausea, or vomiting which prevented oral intake or required therapeutic use of nasogastric tube Symptomatic infection and positive microbiology requiring treatment Documented erythema, discharge requiring antibiotic treatment or wound dehiscence requiring closure Documented clinical (pyrexia, hypoxia and sputum with positive bacteriologic culture) or radiologic diagnosis requiring antibiotic treatment Documented clinical (hypoxia, examination findings) or radiologic diagnosis requiring diuretic therapy New-onset ischemia (electrocardiograms and plasma cardiac markers) or arrhythmia requiring intervention Failure to pass urine requiring insertion of urinary catheter Clinical or radiologic diagnosis requiring intervention
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Analysis On the basis of previous data on postoperative hospital stay for patients undergoing major colonic surgery at our institution, we calculated that 49 patients would be required in each group to detect a 50 percent reduction in postoperative hospital stay with an alpha level of 0.05 and a beta level of 0.2. Therefore, we aimed to include 50 patients in each group. Results were analyzed using SPSS® for Windows® version 14.0 (SPSS, Chicago, Illinois). Results were expressed as median and range. Relationships between groups were assessed using the χ2 test (Pearson chisquared and Fisher exact test, when appropriate) for binary outcomes and the Mann–Whitney U test for continuous variables. Correlations were expressed using Spearman rank correlation coefficients (rho). Statistical significance was accepted at the 5 percent level. ERAS Protocol The ERAS program was developed in a multidisciplinary fashion and received appropriate institutional approval for implementation. This approval included a requirement for a quality assurance framework in the form of a prospective audit of safety and effectiveness. The ERAS protocol used in our institution consists of the following procedures. All patients are seen preoperatively during a dedicated ERAS session. Information about the program, including the daily milestones, is provided. Social issues that would delay discharge are identified and addressed. Patients have a preoperative ward visit. We use preoperative carbohydrate loading (PreOP®, Nutricia; Numico, Zoetermeer, The Netherlands). Our protocols aim for patients to be admitted to the hospital on the morning of their surgery. We avoid mechanical bowel preparation for our open cases. Patients undergoing left-sided operations receive an enema on arrival at the hospital. Patients receive a thoracic epidural infusion of a local anesthetic followed by a general anesthetic. For patients undergoing right-sided operations, we use transverse incisions as appropriate; otherwise we use a midline laparotomy. The protocol aims for limited intraoperative intravenous fluids (1.5 liter crystalloids and 0.5 liter colloids) with a focus on a goal-directed regimen based on urine and hemodynamic indicators. Epidural-related hypotension is treated with vasopressor agents at the discretion of the intensive care unit physicians. Prophylactic nasogastric tubes are not used. On arrival at the ward, patients are mobilized to a chair, and oral intake of fluids is started, aiming for at least 800 ml of oral intake on the day of surgery. Patients receive regular preemptive antiemetics (5-HT3 receptor antagonists as the first choice). On the morning of the first postoperative day, the urinary catheter is removed and patients are provided with a full breakfast and mobilized around the ward. On Day 2, the epidural
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Table 2. Baseline characteristics
ERAS Conventional (n=50) (n=50) Age (yr)
65.6 70.7 (39–92) (40–85)
Sex (no. of patients) Male 26 Female 24 ASA score I 8 II 29 III 13 BMI 28.6 CR-POSSUM Physiologic 10.3 Operative 9.2 Operation (no. of patients) Right hemicolectomy 26 Transverse incision 14 Midline incision 12 Left hemicolectomy 19 Laparoscopic left 4 hemicolectomy Total colectomy 1 Diagnosis (no. of patients) Diverticulosis 2 IBD 1 Adenoma 4 Dukes A 6 Dukes B 15 Dukes C 19 Dukes D 3
P value 0.021†
28 22
0.688‡ 0.688‡
8 31 11 27.4
1.00‡ 0.683‡ 0.640‡ 0.588†
9.7 8.3
†
0.524 0.061†
29
0.546‡
14 7
0.288‡ 0.525‡
0
1.00‡
4 1 2 5 8 21 9
0.674‡ 1.000‡ 0.674‡ 0.749‡ 0.096‡ 0.683‡ 0.124‡
ASA = American Society of Anesthesiologists; BMI = body mass index; CR-POSSUM = Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality; ERAS = enhanced recovery after surgery; IBD = inflammatory bowel disease. ·Data are means with ranges in parentheses unless otherwise stated. ·†Mann–Whitney U test. ·‡χ2 test.
infusion is stopped and the catheter is subsequently removed with oral analgesic cover (regular nonsteroidal anti-inflammatory drugs). Oral opioid analgesics are used only for breakthrough pain. On Day 3, patients are discharged home according to the following discharge criteria: able to eat and drink, adequate analgesia on oral medication, passage of regular flatus, and satisfactory support at home. They are given discharge instructions and a phone number for contacting the ward if required. Nursing staff contact the patients three to four days after discharge for a phone interview, and all patients are followed up in the outpatient clinic within a week of discharge.
RESULTS Data were available for 50 patients in each group. During the recruitment period for the study group (December 2005 to March 2007), ten patients were excluded from the ERAS program; two of these patients had significant renal impairment, two had significant cardiac comorbidity, two
had cognitive impairment, two could not speak sufficient English, and two did not wish to participate in the program. Eight patients treated from September 2004 to September 2005 were excluded from the conventional treatment control group; two patients had renal impairment, two had dementia, one had Addison’s disease, and three had hematologic disorders.
Table 3. CR-POSSUM classification at baseline
ERAS (n=50) Age group (yr) ≤60 8 61–70 15 71–80 21 ≥81 6 Cardiac failure None or mild 38 Moderate 12 Severe 0 Systolic blood pressure (mmHg) 100–170 41 >170 or 90–99 9 <90 0 Pulse (beats per min) 40–100 47 101–120 3 >120 or <40 0 Urea (mmol/l) <10 48 10–15 1 >15 1 Hemoglobin (g/dl) 13–16 27 10–13 or 16–18 22 <10 or >18 1 Median total 10 physiologic score Operative severity Minor 0 Intermediate 0 Major 41 Complex major 9 Peritoneal soiling None or serous fluid 46 Local pus 3 Free pus or feces 1 Operative urgency Elective 50 Urgent 0 Cancer staging No cancer or Dukes 28 A-B Dukes C 19 Dukes D 3 Total operative score 8 (median)
Conventional (n=50)
P value*
14 13 15 8
0.148 0.656 0.211 0.564
30 18 2
0.086 0.190 0.495
30 20 0
0.015 0.015 1.000
43 7 0
0.182 0.318 1.000
45 5 0
0.240 0.204 1.000
22 24 4 9.5
0.317 0.688 0.359 0.524†
2 0 30 18
0.495 1.000 0.015 0.043
47 2 1
0.695 1.000 1.000
50 0
1.000 1.000
20
0.109
21 9 8
0.683 0.124 0.061†
CR-POSSUM = Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality; ERAS = enhanced recovery after surgery. ·Data are numbers of patients unless otherwise indicated. ·*Comparisons made by using χ2 test unless ·* otherwise indicated. ·†Mann–Whitney U test.
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Table 4. Summary of results
ERAS (n=50) Admission >1 day 12 (24) before surgery, no. of patients (%) Epidural analgesia, no. 44 (89) of patients (%) Intraoperative IVF 2 (1–8) (liters) IVF in first 3 days 2 (1–10) (liters) Duration of epidural 2 (0–3) (days) IDC time (days) Time to mobilization 1 (1–3) (days) Time to 1st meal 1 (1–3) (days) Time to flatus (days) 2 (0–8) Postoperative stay 4 (3–34) (days) Total hospital stay 4 (3–34) (days)
Conventional (n=50)
P value*
29 (58)
<0.0001†
38 (76)
0.223†
3 (1–7.5)
<0.0001
6.5 (1–12)
<0.0001
3 (0–4)
<0.0001
3 (1–14) 3 (1–7)
<0.0001 <0.0001
2 (1–15)
<0.0001
3 (0–18) 6.5 (3–18)
<0.0001 <0.0001
8 (4–29)
<0.0001
ERAS = enhanced recovery after surgery; IVF = intravenous fluids; IDC = indwelling urinary catheter. ·Data are medians with ranges in parentheses unless otherwise stated. * Comparisons made by using Mann-Whitney U test unless otherwise indicated. ·†χ2 test. *
Baseline Characteristics At baseline, the ERAS and conventional groups were comparable with respect to sex, body mass index, ASA scores, and physiologic CR-POSSUM scores (Tables 2 and 3). The ERAS group was slightly younger than the conventional group. Intraoperative and Postoperative Variables As can be seen in Table 4, 12 (24 percent) patients in the ERAS group were admitted at least one day before surgery compared with 29 (58 percent) in the conventional group (P<0.001). There was no significant difference in the rate of epidural use between the two groups (P=0.062).The ERAS group received smaller amounts of intraoperative fluids compared with the conventional group (P<0.001). Furthermore, during the first three postoperative days, the ERAS group received significantly smaller volumes of intravenous fluids (P<0.001). The conventional group had longer duration of epidural and urinary catheterization than the ERAS group. The median for successful mobilization was one day for the ERAS group compared with three days for the conventional group (P<0.001). Patients in the ERAS program had their first meal earlier and passed flatus earlier than the conventional group. Median postoperative and total hospital stay (including readmissions) were both 4 days for the ERAS group, compared with 6.5 and 8 days, respectively, for the conventional group (P<
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0.001). Mean (standard deviation) postoperative stay was 5.78 (4.26) days for the ERAS group and 8.32 (5.29) days for the conventional group. Mean total hospital stay was 5.90 (4.36) in the ERAS group and 10.0 (6.27) days in the conventional group. The four patients in the ERAS group who underwent laparoscopic colectomy had a median postoperative stay of 3 (range, 3–3) days compared with 4 (range, 3–7) days in the seven patients who underwent laparoscopic colectomy in the conventional group (P=0.039). The selected patients who had a right hemicolectomy through a transverse incision had a median stay of 3 (range, 3–6) days compared with 6 (range, 3–9) days for those with a midline incision (P=0.002). There were significant correlations between duration of total hospital stay and volume of intraoperative fluids (0.278, P=0.007), volume of postoperative fluids (0.641, P<0.001), duration of indwelling urinary catheter use (0.685, P<0.001), time of first mobilization (0.665, P< 0.001), first meal (0.533, P<0.001), and first flatus (0.494, P < 0.001). There was a strong positive correlation between duration of indwelling urinary catheter use and time of first mobilization (0.660, P<0.001). Complications and Readmissions Table 5 summarizes the outcome variables in each group. Patients in the ERAS group had significantly fewer episodes of urinary tract infection (P=0.004) and ileus (P=0.005). The overall rate of cardiopulmonary complications was also significantly lower in the ERAS group (P=0.032). Four patients in each group required an unplanned return to the operating room. Anastomotic leak resulted in three emergency laparotomies in the ERAS group and two in the conventional group, and wound dehiscence required one reoperation in the ERAS group and two in the conventional group.
Table 5. Number of patients with complications
Urinary infection Ileus Cardiopulmonary Wound Intra-abdominal collection Urinary retention Anastomotic leak Reoperation Readmissions Death Uncomplicated recovery
ERAS (n=50)
Conventional (n=50)
P value*
2 5 11 6 1
12 18 21 10 1
0.008 0.005 0.032 0.275 1.000
5 4 4 6 0 23
3 3 4 7 2 17
0.715 1.000 1.000 0.766 0.495 0.221
ERAS = enhanced recovery after surgery. * Comparisons made by using χ2 test. ·*
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Table 6 summarizes the reasons for and the duration of readmissions. No differences were found between groups in the rate of readmission (P=0.766) or total duration of readmission (P=0.772). One patient in the conventional group died of an acute myocardial infarction after being readmitted. Table 7 shows the extent of compliance with the ERAS protocol. The protocol was not adhered to in all cases. A noncompliance rate of up to 33 percent was found in some areas, resulting in a 40% compliance rate for the target length of postoperative hospital stay.
Table 7. Compliance with ERAS Protocol
Intervention
Target
Compliance (%)
Time from admission to surgery Epidural analgesia Intraoperative IVF Duration of epidural Duration of IDC Time to first meal Time to mobilization Duration of postoperative stay
0 days
80
100% 2 liters 2 days 1 day 1 day 1 day 3 days
92 67 85 80 78 80 40
ERAS = enhanced recovery after surgery; IVF = intravenous fluids; IDC = indwelling urinary catheter.
DISCUSSION This study showed that an ERAS program combining multimodal preoperative care strategies with a well structured care pathway in an environment emphasizing early recovery not only can reduce the duration of hospital stay, but also represents a practical approach for reducing the rate of complications after major colonic surgery. The principle flaw of this study is the retrospective nature of data collection for our control group. Currently very few randomized, controlled trials have been conducted in this field because of the associated practical difficulties.4,10,11 We attempted to select a very comparable control group, and we endeavored to use accessible and reliable end points. Furthermore, we clearly defined our end points and complications to ensure comparable data for the two groups. We had relatively slow recruitment to the ERAS group because we aimed to include only patients undergoing elective surgery who did not require a stoma, had an ASA score < IV, and were operated on by at least one the three senior authors. In our study, patients in the ERAS group were slightly younger than control patients. However, the groups did Table 6. Reasons for and duration of readmissions
ERAS group (n=6) Reason Anastomotic leak Anastomotic leak Colocutaneous fistula Postoperative vomiting Intra-abdominal abscess Urinary infection
Conventional group (n=7)
Duration (days) 5 25 30 1 10 2
ERAS = enhanced recovery after surgery.
Reason
Duration (days)
Wound infection
5
Postoperative ileus Intra-abdominal abscess Postoperative vomiting Pulmonary embolism Myocardial infarction Postoperative ileus
3 20 4 7 (death) 5
not differ regarding the proportion of patients in the age categories defined by the CR-POSSUM scoring system. The conventional group had undergone more complex major operative procedures and also had more cases with Dukes D diagnosis. However, the total operating score was not significantly different. Overall, we believe matching ensured that the groups were comparable at baseline with respect to clinically relevant characteristics. Furthermore, there were no significant correlations between age and any of the monitored outcomes, including the duration of hospital stay. ERAS programs have traditionally been associated with a shortened duration of hospital stay, although programs vary significantly.3–10 The median hospital stay for our ERAS group was four days. The 6.5 days seen in our matched control group was shorter than our hospital’s overall median for colonic surgery (8 days), reflecting the exclusion of patients with significant comorbidities from this matched comparison group. Within each group, a relatively small number of patients underwent laparoscopic surgery (ERAS, four; conventional, seven). The duration of hospital stay for this procedure was significantly shorter for ERAS than for conventional patients. We attribute this difference to the ERAS care pathways, because the patients had similar baseline characteristics, had the same type of surgery, and were operated on by the same surgeon. Other studies have also shown improvements in outcomes when laparoscopic surgery was performed with an ERAS program rather than a conventional approach to recovery,13 suggesting that the benefits of an ERAS program are not limited to patients undergoing open colectomy. Although a number of studies found no significant difference between conventional laparoscopic and open surgery when a fasttrack protocol was used,6,14 another study showed improved outcomes with laparoscopy in an enhanced recovery program.15 In our experience ERAS was associated with a reduced rate of complications as well as decreased length of hospital stay. The reduced rate of urinary infections may relate to the shortened duration of catheterization.16
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Lower observed rates of postoperative ileus may be due to a number of different factors, including effective afferent neural blockade with local anesthetic thoracic epidural, avoidance of opioids, limited intravenous fluids, early feeding, and early mobilization.17–20 Lower rates of cardiopulmonary complications could also be related to the use of epidurals, limited fluids, and early mobilization.7,20–22 A similar reduction in medical complications was observed in earlier studies.7,11 Single-modality interventions may have a smaller individual impact on improvements, and the influence of each intervention is difficult to assess.4,7 For example, although there is a Cochrane review confirming the ileusreducing effects of local anesthetic thoracic epidurals, accelerated recovery and discharge have been achieved in programs where epidurals are not used.23–26 According to a recent meta-analysis, epidurals do not reduce hospital stay for colorectal surgery. However, the studies included in this meta-analysis did not utilize ERAS perioperative care pathways.27 We observed an acceptable readmission rate of 12 percent for our ERAS patients, which is consistent with a number of other similar programs.3,7–10 This may be because of our median hospital stay of four days, compared with two to three days in some other units.7,14 It has been shown that, in an ERAS setting, the planned duration of stay has a significant impact on readmission rates, as well as on levels of patient satisfaction.28 We maintain close community contact with our patients following discharge, enabling patients to call the ward for questions. We also follow up by phone and early clinic visits after discharge, which may contribute to our current readmission rates. Although it was suggested previously that controlled protocols3 may contribute to improved outcomes following surgery, our experience, as well as results from a recent multicenter trial,2 suggest that a number of other factors are essential to ensure effective implementation of such protocols. These include organization of care, unit experience, and dedication to the program, as well as the level of patient education and patients’ commitment to the pathways. When analyzing protocol compliance within our program, we observed that the median date for each component of the program met the predefined target date of our protocol, with a relatively small proportion of noncompliance rates for each category. We mainly attribute this to close involvement of nurses with this program, nursing education, and structured ERAS nursing care pathways, as well as to close collaboration between anesthetists and surgeons. Protocol compliance is the key to success of ERAS. As noted, patients with smaller amounts of perioperative fluids and earlier mobilization passed flatus earlier, and were subsequently discharged
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home earlier. However, our median discharge date was four days, which was longer than the planned three days in our protocol. Only 40 percent of our patients were discharged on Day 3. To achieve an overall shorter duration of stay, each individual patient should reach the predefined target days for all components of the program. Our observed compliance rates were not adequate to achieve this. Further strategies which we may need to consider incorporating into our protocols include the use of highflow oxygen, routine laxatives, and the esophageal Doppler for accurate, cardiac-output directed management of intraoperative fluids. These strategies may reduce the rate of wound infections, accelerate the return of bowel function, and reduce overall morbidity.29–32 Several studies have suggested various benefits of perioperative oxygen therapy. There is evidence indicating that patients who receive high perioperative inspired oxygen have a significantly reduced risk of wound infection,33–35 as well as a reduced incidence of postoperative nausea and vomiting.36,37 Laxatives have been used in a number of ERAS programs7,13 as a method to hasten the return of bowel function. There is a recent study which has shown that laxatives improve recovery of bowel function after fast-track hysterectomy.38 Our program is run within an elective-only surgical facility. Currently there is little emphasis on the suitable environmental settings for an ERAS ward. We have some preliminary data which suggest that patients may recover more quickly in an elective-only unit.39 Thus, we propose that environment should be considered a key ERAS element. The surgical ward should be considered as a postoperative rehabilitation unit, characterized by separation of acutely admitted patients from elective patients and a ward design which facilitates the feeling of security, encourages independence, and allows free access to food preparation and self-care facilities.40 In conclusion, our ERAS program was associated with a reduced duration of hospital stay and a decreased rate of complications. Our data indicate that these pathways are safe and should be considered for introduction into routine clinical practice. REFERENCES 1. Kehlet H, Dahl JB. Anaesthesia, surgery, and challenges in postoperative recovery. Lancet 2003;362:1921–8. 2. Maessen J, Dejong CH, Hausel J, et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 2007;94:224–31. 3. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW. 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 2003;46:851–9.
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