title: Fast-track colorectal surgery: protocol adherence influences postoperative outcomes.
abstract: OBJECTIVE
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of General Surgery, Misericordia and Dolce Hospital, Piazza dell'Ospedale 5, 59100 Prato, Po, Italy. fferoci@yahoo.it
authors.forename: Francesco
authors.initials: F
authors.lastname: Feroci
authors.forename: Elisa
authors.initials: E
authors.lastname: Lenzi
authors.forename: Maddalena
authors.initials: M
authors.lastname: Baraghini
authors.forename: Alessia
authors.initials: A
authors.lastname: Garzi
authors.forename: Andrea
authors.initials: A
authors.lastname: Vannucchi
authors.forename: Stefano
authors.initials: S
authors.lastname: Cantafio
authors.forename: Marco
authors.initials: M
authors.lastname: Scatizzi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D015331:Cohort Studies; D003082:Colectomy / Q000379:methods; D003108:Colonic Diseases / Q000601:surgery; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay / Q000706:statistics & numerical data*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010359:Patient Readmission / Q000706:statistics & numerical data*; D019990:Perioperative Care / Q000379:methods* / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D011446:Prospective Studies; D012002:Rectal Diseases / Q000601:surgery; D012007:Rectum / Q000601:surgery*; D016896:Treatment Outcome