Implementing a fast-track protocol for patients undergoing bowel resection: not so fast

Am J Surg. 2013 Aug;206(2):152-8. doi: 10.1016/j.amjsurg.2012.11.019. Epub 2013 Jun 4.


Background: Multimodality fast-track protocols have been shown to enhance recovery after bowel resection. However, it remains unclear which of the components impact outcomes and whether processes actually occur as intended.

Methods: Consecutive patients who underwent elective bowel resection at a university teaching hospital under a standardized fast-track recovery protocol were compared with patients who underwent similar procedures before protocol initiation. Compliance was measured with the 7 major elements of the protocol: administration of nonopioid analgesia, perioperative lidocaine, nasogastric tube removal, early feeding, early ambulation, and fluid restriction.

Results: Eighty pathway patients were compared with 87 conventional patients. Only 3 of the 7 major components were successfully implemented. Fluid restriction was achieved in only 2 patients. Pain scores and ileus-related morbidities were comparable with the exception of nasogastric tube reinsertion, which was required twice as often in pathway patients (17 vs 8, P = .02). Thirteen pathway patients were readmitted compared with 7 control patients (P = .11).

Conclusions: The delivery of expected care cannot be assumed. There was no discernible benefit in patient outcomes.

Keywords: Compliance; Ileus; Pathway.

Publication types

  • Comparative Study

MeSH terms

  • Analgesics / administration & dosage
  • Anastomosis, Surgical / adverse effects
  • Anesthetics, Local / administration & dosage
  • Clinical Protocols*
  • Drinking
  • Early Ambulation
  • Eating
  • Female
  • Hospitals, University
  • Humans
  • Ileus / surgery*
  • Intestines / surgery*
  • Intubation, Gastrointestinal
  • Length of Stay / statistics & numerical data
  • Lidocaine / administration & dosage
  • Male
  • Middle Aged
  • Pain, Postoperative / drug therapy
  • Pain, Postoperative / etiology
  • Patient Readmission / statistics & numerical data*
  • Risk Factors
  • Treatment Outcome


  • Analgesics
  • Anesthetics, Local
  • Lidocaine