title: Introducing an enhanced recovery after surgery program in colorectal surgery: a single center experience.
abstract: OBJECTIVE
  To study the implementation of an enhanced recovery after surgery (ERAS) program at a large University Hospital from "pilot study" to "standard of care".
  
  
  METHODS
  The study was designed as a prospective single centre cohort study. A prospective evaluation of compliance to a protocol based on full application of all ERAS principles, through the progressive steps of its implementation, was performed. Results achieved in the initial pilot study conducted by a dedicated team (n = 47) were compared to those achieved in the shared protocol phase (n = 143) three years later. Outcomes were length of postoperative hospital stay, readmission rate, compliance to the protocol and morbidity. Primary endpoint was the description of the results and the identification of critical issues of large scale implementation of an ERAS program in colorectal surgery emerged in the experience of a single center. Secondary endpoint was the identification of interventions that have been proven to be effective for facilitating the transition from traditional care pathways to a multimodal management protocol according to ERAS principles in colorectal surgery at a single center.
  
  
  RESULTS
  During the initial pilot study (March 2009 to December 2010; 47 patients) conducted by a dedicated multidisciplinary team, compliance to the items of ERAS protocol was 93%, with a median length of hospital stay (LOS) of 3 d. Early anastomotic fistulas were observed in 2 cases (4.2%), which required reoperation (Clavien-Dindo grade IIIb). None of the patients had been discharged before the onset of the complication, which could therefore receive prompt treatment. There were also four (8.5%) minor complications (Clavien-Dindo grade II). Thirty days readmission rate was 4%. Perioperative mortality was nil. After implementation of the protocol throughout the Hospital in unselected patients (May 2012 to December 2012; 147 patients) compliance was 74%, with a median LOS of 6 d. Early anastomotic fistulas were observed in 11 cases (7.7%), 5 (3.5%) of which required reoperation (Clavien-Dindo grade IIIb). Two early anastomotic fistulas were treated by radiologic/endoscopic manoeuvres and 4 were treated conservatively. There were also 36 (25.2%) minor complications, 21 (14.7%) of which were Clavien-Dindo grade II and 15 (10.5%) of which were Clavien-Dindo grade I. Only two patients whose course was adversely affected by the development of an anastomotic leak had been discharged before the onset of the complication itself, requiring readmission. Readmission rate within 30 d was 4%. Perioperative mortality was 1%.
  
  
  CONCLUSIONS
  Our results confirm that introduction of an ERAS protocol for colorectal surgery allows quicker postoperative recovery and shortens the length of stay compared to historical series.
authors.affiliation: Stefano Bona, Mattia Molteni, Riccardo Rosati, Ugo Elmore, Pietro Bagnoli, Roberta Monzani, Monica Caravaca, Marco Montorsi, Department of General Surgery, University of Milan School of Medicine, Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Bona
authors.affiliation: Stefano Bona, Mattia Molteni, Riccardo Rosati, Ugo Elmore, Pietro Bagnoli, Roberta Monzani, Monica Caravaca, Marco Montorsi, Department of General Surgery, University of Milan School of Medicine, Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Molteni
authors.affiliation: Stefano Bona, Mattia Molteni, Riccardo Rosati, Ugo Elmore, Pietro Bagnoli, Roberta Monzani, Monica Caravaca, Marco Montorsi, Department of General Surgery, University of Milan School of Medicine, Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Rosati
authors.affiliation: Stefano Bona, Mattia Molteni, Riccardo Rosati, Ugo Elmore, Pietro Bagnoli, Roberta Monzani, Monica Caravaca, Marco Montorsi, Department of General Surgery, University of Milan School of Medicine, Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
authors.forename: Ugo
authors.initials: U
authors.lastname: Elmore
authors.affiliation: Stefano Bona, Mattia Molteni, Riccardo Rosati, Ugo Elmore, Pietro Bagnoli, Roberta Monzani, Monica Caravaca, Marco Montorsi, Department of General Surgery, University of Milan School of Medicine, Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Bagnoli
authors.affiliation: Stefano Bona, Mattia Molteni, Riccardo Rosati, Ugo Elmore, Pietro Bagnoli, Roberta Monzani, Monica Caravaca, Marco Montorsi, Department of General Surgery, University of Milan School of Medicine, Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
authors.forename: Roberta
authors.initials: R
authors.lastname: Monzani
authors.affiliation: Stefano Bona, Mattia Molteni, Riccardo Rosati, Ugo Elmore, Pietro Bagnoli, Roberta Monzani, Monica Caravaca, Marco Montorsi, Department of General Surgery, University of Milan School of Medicine, Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
authors.forename: Monica
authors.initials: M
authors.lastname: Caravaca
authors.affiliation: Stefano Bona, Mattia Molteni, Riccardo Rosati, Ugo Elmore, Pietro Bagnoli, Roberta Monzani, Monica Caravaca, Marco Montorsi, Department of General Surgery, University of Milan School of Medicine, Humanitas Research Hospital, 20089 Rozzano, Milan, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Montorsi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003106:Colon / Q000601:surgery*; D019091:Critical Pathways / Q000592:standards; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000401:mortality / Q000534:rehabilitation* / Q000592:standards; D005260:Female; D019983:Guideline Adherence; D006785:Hospitals, University; D006801:Humans; D007558:Italy; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D010865:Pilot Projects; D011182:Postoperative Care; D011183:Postoperative Complications / Q000601:surgery; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D015397:Program Evaluation; D011446:Prospective Studies; D020127:Recovery of Function; D012007:Rectum / Q000601:surgery*; D012086:Reoperation; D059039:Standard of Care; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Colorectal surgery; Compliance to enhanced recovery after surgery protocol; Enhanced recovery after surgery; Fast-track surgery; Implementation of enhanced recovery after surgery protocol