8 improved outcomes in colon and rectal surgery 78. Petrelli NJ, Stulc JP, Rodriguez-Bigas M, Blumenson L. Nasogastric decompression following elective colorectal surgery: a prospective randomized study. Am Surg 1993; 59(10): 632–5. 79. Pickleman J, Lee RM. The management of patients with suspected early postoperative small bowel obstruction. Ann Surg 1989; 210(2): 216–9. 80. Miller G, Boman J, Shrier I, Gordon PH. Readmission for small-bowel obstruction in the early postoperative period: etiology and outcome. Can J Surg 2002; 45(4): 255–8. 81. Beck DE, Opelka FG, Bailey HR, Rauh SM, Pashos CL. Incidence of small-bowel obstruction and adhesiolysis after open colorec- tal and general surgery. Dis Colon Rectum 1999; 42(2): 241–8. 82. Senagore AJ. Pathogenesis and clinical and economic con- sequences of postoperative ileus. Am J Health Syst Pharm 2007; 64(20 Suppl 13): S3–7. 83. Lobo DN, Bostock KA, Neal KR et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomized controlled trial. Lancet 2002; 359(9320): 1812–8. 84. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA. A prospective randomized controlled trial of multimodal periop- erative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 2007; 245(6): 867–72. 85. Bradshaw BG, Liu SS, Thirlby RC. Standardized periopera- tive care protocols and reduced length of stay after colon surgery. J Am Coll Surg 1998; 186(5): 501–6. 86. Fukuya T, Hawes DR, Lu CC, Chang PJ, Barloon TJ. CT diagnosis of small-bowel obstruction: efficacy in 60 patients. Am J Roentgenol 1992; 158(4): 765–9. 87. Wolff BG, Weese JL, Ludwig KA et al. Postoperative ileus- related morbidity profile in patients treated with alvimopan after bowel resection. J Am Coll Surg 2007; 204(4): 609–16. 88. Viscusi ER, Goldstein S, Witkowski T et al. Alvimopan, a peripherally acting mu-opioid receptor antagonist, compared with placebo in postoperative ileus after major abdominal surgery: results of a randomized, double-blind, controlled study. Surg Endosc 2006; 20(1): 64–70. 89. Senagore AJ, Bauer JJ, Du W, Techner L. Alvimopan acceler- ates gastrointestinal recovery after bowel resection regardless of age, gender, race, or concomitant medication use. Surgery 2007; 142(4): 478–86. 90. Smith AJ, Nissan A, Lanouette NM et al. Prokinetic effect of eryth- romycin after colorectal surgery: randomized, placebo-controlled, double-blind study. Dis Colon Rectum 2000; 43(3): 333–7. 91. Bonacini M, Quiason S, Reynolds M et al. Effect of intrave- nous erythromycin on postoperative ileus. Am J Gastroenterol 1993; 88(2): 208–11. 92. Roberts JP, Benson MJ, Rogers J et al. Effect of cisapride on distal colonic motility in the early postoperative period following left colonic anastomosis. Dis Colon Rectum 1995; 38(2): 139–45. 93. Tollesson PO, Cassuto J, Rimbäck G et al. Treatment of postoperative paralytic ileus with cisapride. Scand J Gastroenterol 1991; 26(5): 477–82. 94. Brown TA, McDonald J, Williard W. A prospective, ran- domized, double-blinded, placebo-controlled trial of cisapride after colorectal surgery. Am J Surg 1999; 177(5): 399–401. 95. Reissman P, Teoh TA, Cohen SM et al. Is early oral feeding safe after elective colorectal surgery? A prospective random- ized trial. Ann Surg 1995; 222(1): 73–7. 96. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24 hours of colorectal surgery versus later commence- ment of feeding for postoperative complications. Cochrane Database Syst Rev 2006; (4): CD004080. 97. Han-Geurts IJ, Hop WC, Kok NF et al. Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery. Br J Surg 2007; 94(5): 555–61. 98. Stamos MJ, Theuer CP, Headrick CN. General postop- erative complications. 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Care paths and optimal postop management Surya P M Nalamati and Eric J Szilagy CHALLENGING CASE A 45-year-old man undergoes an open sigmoid colectomy for diverticular disease and is placed on a postoperative care path. On postoperative day three, the patient is ambulating, has mild nausea, and has not passed flatus. CASE MANAGEMENT The care path is modified to continue intravenous fluids. The patient-controlled analgesia is stopped and the patient is started on small doses of intravenous narcotics. Ambulation is continued. INTRODUCTION The constant endeavor of modern medicine has been to improve the quality of patient care. Over the past century there have been tremendous technological advances in medicine and sur- gery. The pattern of care has evolved from being a single physi- cian managing one patient’s care to team care involving one or more physicians from same or different fields of specialization, residents, nurses, physician assistants, social workers, and case managers. However, these advances have increased health care delivery costs, which in turn demanded a system of care to be developed that is more efficient without compromising patient safety and the quality of health care. Care paths are one of the most wide spread tools used to enhance outcomes and contain costs.(1) Introduced in early1990s in the United Kingdom and United States, they have rapidly gained acceptance and are now being used all over the world. Care paths are structured, multidisciplinary plans of anticipated care, set in an appropriate time frame, to help patients with spe- cific conditions or sets of symptoms, move progressively through a clinical experience to a positive outcome. Numerous synonyms exist for care paths including clinical pathways, critical care path- ways, integrated care pathways, critical paths, multidisciplinary pathways of care, and care maps.(2, 3) Fast-track surgery and ERAS (enhanced recovery after surgery) programs are recent evolutions of the care paths concept.(4–6) Critical pathways, successfully utilized in several different business sectors, including construction and automotive industries, have been adapted and applied to medical field.(7–11) They are designed to support the implementation and translation of national guidelines, or an evidence-based standard of care, into local protocols. The anticipated result is the subsequent application of pathways to clinical practice, clinical and nonclinical resource management, clinical audit, and financial management.(2) They provide detailed guidance for each stage in the management of a patient (diagnosis, treatment, interventions etc.,) for a specific, given condition over a period of time. They encompass the progress of patient care and document details of outcome.(12) Clinical pathways have four main components: a time line, the categories of care or activities and their interventions, interme- diate and long-term outcome criteria, and the variance records, which allows deviations to be documented and analyzed.(2) Care paths differ substantially from clinical guidelines, proto- cols, and algorithms. Clinical guidelines are consensus state- ments that are systemically developed to assist practitioners in making patient management decisions related to particular clinical circumstance.(13) Protocols are treatment guidelines that are developed based on clinical guidelines.(14) Although anchored in clinical guidelines, care paths are designed to be used by multidisciplinary teams and focus on details of the process of care and highlight inefficiencies. Care paths in con- trast to guidelines contain a continuous monitoring and data evaluation component. This helps in identifying the rate limit- ing steps and to make any evidence-based changes in the care path to improve the overall process of care. CARE PATHS IN COLON AND RECTAL SURGERY Care paths in surgery are used in the management of patients under- going commonly performed surgical procedures.(15) In colon and rectal surgery, care paths have been successfully initiated since the early1990s. Care paths have been used in the management of peri- operative care where they were more procedure specific. They have been successfully used in management of standard colon resection, laparoscopic colon resections, complex cases such as restorative proctocolectomy, and complex anorectal reconstructions.(16–20) The objectives of care paths, as reviewed by Pearson et al., were to select the best demonstrated practice when practice varied unneces- sarily.(21) He outlined the process guidelines as follows: Define the standards for the expected duration of hospital stay and for the use of tests and treatments. These standards are evidence-based or based on guidelines for the specific clinical cir- cumstance. For example, Stephen et al. noted in their article, that before implementation of pathways patients had their nasogastric tubes removed after they passed flatus.(22) During development of their care path for colonic resection, evidence for the routine use of nasogastric tube which was a rate-limiting step for early recovery was reviewed. Evidence showed that routine prophylac- tic decompression with nasogastric tube decompression is of no use and should be abandoned.(23) This led to incorporating the step to remove the nasogastric tube on the day of the surgery, which has become now widely accepted clinical practice. To examine the interrelations among the different steps in the • care process and find ways to coordinate or decrease the time in the rate-limiting step. To give all the care providers a common plan from which to view • and understand their various roles in overall care process. To provide a framework for collecting data on the care pro- • cess so that providers can learn and analyze how often and why patients do not follow an expected course. To decrease documentation burdens and improve patient satis- • faction with care by educating patients and their families about the plan of care. improved outcomes in colon and rectal surgery DEFINING AND IMPROVING OUTCOME MEASURES Surgical care outcomes have been defined by a variety of measures. Complication rates relating to abnormal outcomes, such as infection, hemorrhage, organ system dysfunction, and reconstruction failure, are common benchmarks for surgical performance. These rates have been the targets of quality improvement because they have impact not only on morbidity but also mortality. However, these outcome measures, although significant, do not necessarily reflect the effort of the entire surgical team or the efficiency of the care process. Length of stay, rate of return of physiologic function, and quality of life measures are cumulative standards that also take into account the impact of multiple caregivers. They may not only correlate with lower morbidity and mortality, but provide additional metrics for the result of a multidisciplinary team approach.(24) The cumula- tive effect of introducing efficiency in the multidisciplinary effort is improved utilization of resources, with higher quality, using fewer resources at a lower cost. Traditionally, the hospital stay after colonic resection varied be - tween 5 and 10 days with a median of 7 days and a complication rate of 10–20%.(25, 26) Implementation of care paths has signifi- cantly reduced this number. Archer et al. reported a mean length of stay decrease from 10.3 to 7.5 days, and average hospital charges from $21,650 to $17,958 (20) whereas Billingham et al., in their series of 263 patients, reported stay of 5.5 vs. 8.2 days and hospital charges $12,672 vs. $16,665 (19). Even though the decreased length of stay and cost benefits appear to be obvious, it is not clear in these studies if there is significant shifting of costs from hospital care to home care. BENEFITS OF CARE PATHS Care paths provide explicit and well-defined standards for care. They support introduction of evidence-based medicine and use of clini- cal guidelines thus reducing variations in patient care and improving clinical outcomes.(27) They improve multidisciplinary communica- tion, interprofessional collaboration, teamwork, and care planning. (28) Care paths implement continuous clinical audit, providing a means of continuous quality improvement, thus providing a base- line for future initiatives to modify the pathway. Care paths reduce risk, support training, optimize resources, and reduce costs, which contribute to shortening the hospital stay. Care paths are not pre- scriptive; they do not override clinical judgment. On the contrary, the surgeon can at any time elect not to follow the pathway based on his clinical judgment. One of the most useful characteristic of care paths is that they provide a visual overview of each patient’s care with spe- cific outcomes stated. This can be reviewed and acted on by every one caring for the patients, as well as by patients themselves.(20) Using care paths designed around evidence-based data and standards of practice, one could expect a decrease in overall malpractice risk.(29) DEVELOPMENT OF CARE PATH The development and implementation of care paths consist of the following steps as reviewed in numerous publications.(1, 14, 19, 21, 22, 30, 31) Select a Topic Topic selection for formulating a care path could be either disease or procedure specific. High volume, high-cost diagnoses or proce- dures are ideal. Critical pathways development in colorectal surgery concentrated on high volume and high cost procedures like colec- tomies, restorative total proctocolectomies, and complex anorectal reconstructions.(5, 16, 19, 20, 22) Most of the care paths developed in colon and rectal surgery are procedure specific and aimed at perioperative management. These procedures are more suitable for pathway development because of the predictable course of events before and after hospitalization, and variations in care associated with them. Development of care paths makes the goal of decreased variation and improved resource utilization possible. Select a Team A multidisciplinary team is the most critical element of any care path. Historically, care paths were developed by and for nurses and other nonphysician hospital-based workers. However, the lack of physician participation led to failure of that model of care pathway.(32, 33) The active role of surgeons in a leadership role is crucial to development and implementation of pathways. In addition, it is vital to involve representatives from all groups that will play a role in implementation of pathway. The team should discuss all the elements of the pathways. The team should meet regularly to develop the pathway and after implementation to dis- cuss variances and make appropriate revisions to it. Colon and rectal care path teams consist of surgeons, house staff, physician assistants, stoma nurses, office nurses for preop- erative care planning, ward nurses, physical therapists, and social workers to plan the home care needs and arrange them in a timely fashion. Timely intervention by each of the team members is essential for success of the care path. Evaluate the Current Process of Care A careful review of the medical records should be performed to identify the critical intermediate outcome, rate limiting steps, and high cost areas on which to focus. Evaluation can be automated where electronic medical systems are available. This should include review of the preop process (preanesthesia work up, obtaining necessary consults, stoma training if needed, antibiot- ics, anti coagulation) and the postop process. In our initial review process, during the development of care pathways, we found that nasogastric intubation, postoperative feeding, GI function recov- ery time, and mobilization to be the important rate limiting steps. Further development will be based on intraoperative anesthesia care, and postoperative pain management. Evaluate Medical Evidence and External Practices After defining the rate limiting steps, the team should evaluate lit- erature for evidence of the best-demonstrated practice. For most of the rate limiting steps in colon rectal surgery there is data avail- able. In the absence of evidence, comparison with other institutes to set up a benchmark is the most reliable method. These steps should be then incorporated into the care path. Establish Goals and Endpoints A reasonable objective should be established as a goal, which serves as an endpoint for the care path. Multiple goals can be established involving each aspect of care in the pathway, and the successful achievement of each of these landmarks would define the success of care path. For example, in our care path for colon surgery (see Figures 9.1 and 9.2), the goal of the pathway is to care paths and optimal postop management Aspect of Care PRE-HOSPITAL PRE-OP/DAY OF POST_OP/DAY OF POST_OP/DAY 1 POST_OP/DAY 2 SURGERY Date_____ SURGERY Date_____ Date________ Date________ CONSULTS Surgery/PCP Anesthesia class3 Anesthesia ostomy/ET consult ET for elective stoma TESTS CBS,chem 7, Platelets CBS,chem 7 (only if blood EKG & CXR, as Type and Screen loss or metabolic issue) needed only Bed rest, Reposition q 2-4 hr Ambuiate X 4 Ambuiate X 4 Increase Dangle Post-op eve______ 1. 2. 3. 4 1. 2. 3. 4 ACTIVITY Ankle Pumps, C&DB Increase freq & distance Increase freq & 50ft to 100ft distance 50ft to 100ft Spirometry No NG unless obstructed. NG_____ IV, Dressing SED NG_______ NG_______ Incentive spirometry IV, de dressing, SED TREATMENTS IV, Dressing, Pulse Ok Wean O2 Spirometry Incentive spirometry, Pulse Ok Incentive Bowel prep day Analgesia: PCA____ Analgesia: PCA____ Analgesia: PCA____ before surgery Epidural_____ Epidural_____ Epidural_____ dc___ Routine meds as DVT prophylaxis Other_____ Other_____ Other_____ All routine meds indicated by MD Resume pre-hospitalization Resume meds PO if tolerated meds Bowel prep day I&O dc Foley______ (leave before surgery Confirm bowel prep Monitor I & O Foley in if fluid status problem ELIMINATION Monitor I & O Foley or Epidural Bladder scan post vaid straight cath Clear Liquids when DIET Clear fluids per MD NPO after midnight NPO/Ice chips Sips of clear liquids tolerating 800cc clear liquid advance to PO#1 diet_____ Consult CRM if Consult CRM: estabilish Consult CRM: confirm DISCHARGE PLAN needs identified Consult CRM discharge dispositional discharge plan by nurse screen or MD needs Pre-op education Post-op education, C&DB, SED, TEACHING re:bowel prep, post op pre-op teaching Incentive spirometry, early Introduce ostomy Ostomy education activities, pain ambulation education management_____ REVIEW Days Initials_______ Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____ PATH Eves Sign/title_______ Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____ WAY Nights Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____ Figure 9.1 Care Path for Colon Surgery. improved outcomes in colon and rectal surgery Aspect of Care POST-OP/DAY 3 POSTE-OP/DAY 4 COMMENTS OUTCOMES Date____________ Date____________ CONSULTS Clear discharge with consulting MD Appropriate referrais pre-op TESTS Ambulate in atleast ACTIVITY 4 times(50 ft —100 ft) Ambulate independently, Elimination of post-op complications Progressively increase or with aids as required related to immobility distance/frequency TREATMENTS Transfer IV to saline lock Monitor No post-op infections Analgesia: change to PO pain PO analgesia Effective pain management medication if tolerating fluids Monitor I&O Monitor I&O ELIMINATION Monitor bowel function: Monitor bowel function: Effective bowel and bladder functon Flatus__________ Flatus__________ re-estabilished DIET PO # 1 diet Diet/Low Residue Adequate nutritional intake Dietary consult if needed Consult CRM: Finalize discharge plan obtain supplies and equipment. DISCHARGE PLAN Complete discharge, W-10. Consult CRM: review Discharge by post-op day #4 Consider discharge if tolerating PO & finalize Discharge plan Passing flatus if needs identified by nurse screen or MD Reinforce ostomy education. Incerase Patient/Family will TEACHING patient participation. Review diet, Review diet, activity understand and participate activity and medication. meicaton and home care in plan REVIEW Days Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____ PATH Eves Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____ WAY Nights Initials:___Sign/title:____ Initials:___Sign/title:____ Initials:___Sign/title:____ Figure 9.2 Care Path for Colon Surgery (Continued). care paths and optimal postop management discharge the patient on postoperative day 4, and if possible on day 3. The subgoals that were established were based on the aspect of care such as to ambulate on day 1 after surgery, remove the Foley catheter on day 2, etc. Goals should also be established for achieving patient satisfaction, as measured by survey tools such as those used by Press Ganey Associates.(34) Determine Critical Pathway Format There are multiple formats, which can be used; most of them have a task-time matrix in which specific tasks are specified along a time line. Care paths range from different kinds of man- ual formats to electronic format, where electronic charting, and pathway compliance are obtained simultaneously.(31, 35) Implement the Care Path Education of all the involved caregivers, patients, and their families is the key to successful implementation of a care path. In-service education should be given to all the involved groups, especially if electronic care paths are used.(36) Different individuals in the care path should be assigned specific functions such as collection of data, analyzing variance etc. Document and Analyze Variance Implementation of the pathway is only the first action of care path. This must be followed by data collection analysis and then process improvement to achieve the set goals. A good tool suited for this purpose is the analysis of variance grids.(27) By examin- ing the variance sheets that record variances in implementation of pathway regularly, it will be easier to identify common reasons for noncompliance. These issues can be discussed with the team to see if any changes can be made for full implementation of care path. OUR INSTITUTIONAL EXPERIENCE Care pathways for colon surgery were initiated in 1995 at our institute. This was used for both standard and laparoscopic colon resections. The care path was designed with an aim of providing optimal care in a cost effective manner. The goal of the pathway is to discharge patients by postoperative day 4 and when possible on day 3. The endpoint of the pathway is to discharge the patient home when tolerating diet and passing flatus. The documenta- tion for the pathways was of paper format and had boxes to check and spaces for writing notes to document the progress. The pathway starts with preoperative patient teaching during their office visit. Patients are informed about the procedure, the length of stay and anticipated days for landmarks of progress, such as ambulation, advancement of diet and return of bowel func- tion, and discharge. They are also provided with a printed copy of the care path guide, which is especially designed for patients, that details preoperative preparation, what to expect on arrival to hospital, and postoperative care scenario. Patients are encour- aged to call if they have any doubts regarding the care path. A complete blood count, chemistries are ordered for every patient. Electrocardiogram and chest x-rays are ordered for patients if needed. Patients undergo bowel preparation at home the day before surgery, using Golytely. On the day of surgery the patients receive Heparin 5000 units subcutaneously, and antibiotics in the preoperative period. Antibiotics are administered for 24 hours and heparin is given throughout their hospital stay. Antiembolism devices such as Venodynes are put on preoperatively. The anesthesiologist places an epidural catheter if the patient consents to it. Postoperatively, the patient is admitted to a regular surgical unit, and vitals monitored every 4 hours during the entire length of hospitalization. The patient is given an incentive spirometer and its use demonstrated. On postoperative day 1 they are ambu- lated. Patients are given sips of clear liquids and if tolerated given a clear liquid tray. Stoma education is introduced on day 2 if indicated. Patients on postop day 2 are given unrestricted clear liquids and advanced to regular diet if tolerating 800 cc of clear liquids. Foley catheter is also removed. In addition, the epidural or patient controlled anesthesia (PCA) are discontinued and the patient is started on oral pain medications. Discharge disposition needs are established. On postoperative day 3, patients are given a regular diet; discharge paperwork is completed and kept ready. If the patient tolerates diet and passes flatus they are discharged; if not, the patient is discharged on postoperative day 4 after meeting the discharge criteria. Before discharge, the diet, activ- ity, medication, and homecare instructions are reviewed with the patient and follow up appointments are set up. The Care path was routinely analyzed at interdisciplinary conferences. (Refer to Figures 9.1 & 9.2). CHALLENGES AND CONCERNS Many surgeons believe that their responsibility to practice medi- cine economically is becoming secondary to their responsibility of practicing medicine effectively.(37) Common reluctance to accept care paths arises from a preju- dice in viewing them as a form of “cookbook” medicine.(38, 39) Some consider them to be intrusive, decreasing the physician’s autonomy, and lack the element of individualized care for each patient. However, although care paths encourage standardiza- tion as a strategy to improve quality and efficiency, physicians, by helping define these standards, actually would gain greater control over the patient care rather than losing their autonomy. Physicians also need to be free to write orders to change the pathway or to remove the patient from the pathway if needed. Documenting the reasons to do so would help in analyzing the pathway processes and lead to improvement in the pathway. This would increase the acceptance of care paths and also counter the criticism of deficiency of individual care. Although many studies report cost savings in implementa- tion of care paths, most of these do not address the issue of cost of development of care paths. Macario et al. estimated the cost of development of the care path for patients undergoing knee replacement surgery at $21,000.(40) However these did not take into account the time staff physicians spent on the project. There is a concern among the academic faculty that the care paths when used in resident training environments may discourage experimentation, independent thinking, and application of appro- priate clinical judgment to individual cases. Those responsible for house staff education may feel care paths might stifle the question- ing through which residents learn. However medical training might be well served by incorporating methods such as critical pathways to teach students evidence-based and cost-effective practice.(21) improved outcomes in colon and rectal surgery Care pathways may serve to frame the educational process. They are based on expected physiological outcomes, but are monitored so that variances (i.e., complications) can be addressed with the use of clinical judgment. The clinical judgment is, in effect, the imple- mentation of an expanded path or alternate pathway. The alternate pathway, for example, may be for postoperative myocardial infarc- tion management. Pathways are structured but dynamic. There is also a concern that care paths might create an atmos- phere in which patients will be steered away from clinical research studies into treatment according to critical pathways. Including a step in the care path can offset this. If set criteria are met, the patient should be considered for the appropriate clinical trial and the research team would be contacted. This would actually yield in improved recruitment to clinical studies. Research ques- tions can themselves be embedded in care paths and answers be obtained on analysis of the care paths. Another frequently voiced concern is that physicians may be more vulnerable to malpractice suits if they do not comply with a care path and a patient has a complication. In essence, litigation is more likely to occur when there is a failure to follow a pathway based on standards of care. Careful documentation as to reason for deviation from the pathway could potentially decrease the chance of litigation. REALISTIC EXPECTATIONS Despite the successful use of care paths for optimal management of postoperative patients undergoing colon and rectal surgeries, it should be noted that the pathways are oriented towards ideal patients with predictable course of care. Enthusiasm to man- age every patient with the care path without paying attention to individual circumstance could be counterproductive. Hence, care paths should be designed to recognize patients with special needs or comorbidities. Perioperative pathways that consider the needs of diabetics, cardiac patients, pulmonary patients, or stroke patients for example, would be a proactive way to institute risk- reducing strategies that would have a positive impact in reducing perioperative morbidity and mortality. Tremendous scope for improvement still exists in implementa- tion of evidence-based management. In a recent article, Kehlet et al. reviewed the care after colonic surgery in Europe and the United states and analyzed the use of evidence-based care in the perioperative period.(41) They identified mechanical bowel prep- aration, operative techniques, nasogastric intubation, time frame for postoperative food, and fluid intake, time to recovery from GI function, and mobilization as the important variables, which have positive evidence-based practices. They noted preoperative bowel preparation was used in >85% of patients. The nasogastric tube was left in situ postoperatively in 40% vs. 66% of patients in the United States and Europe, respectively. It took 3–4 days for 50% of patients tolerating liquids. This suggests that clinical practice does not optimally reflect published evidence and indi- cates a potential for major improvement. FAST TRACK COLON AND RECTAL SURGERY Fast track surgery is an evolution in the care path approach that involves rapid progress from perioperative preparation, through surgery, and discharge from hospital. Synonyms used for this include accelerated postoperative recovery programs and enhanced recovery programs. Critical elements of fast track colon surgery paths include use of the following: extensive preoperative coun- seling, no bowel preparation, no premedication, administration of short acting anesthetic drugs, standardized surgical procedure, minimal access techniques, restriction of drains, and catheters, early extubation, rewarming and sustained postoperative normo- thermia, optimal pain control, avoiding opiates for pain control, early ambulation and discharge, and follow up after discharge. (2, 5, 16, 17, 42–44) Factors that limit early discharge include pain, nausea, vomit- ing, prolonged ileus, mechanical factors such as drains, indwell- ing catheters, and stress-induced organ dysfunction.(6, 45) Kehlet and Mogensen, in their study involving 18 patients who under- went open sigmoid colectomy, addressed these factors by imple- menting a multimodal rehabilitation program.(43) It involved a highly scripted preoperative and postoperative care path regu- lating the introduction of epidural analgesia, diet, and ambula- tion. The pathway involved mobilization of patients on the day of surgery, administering cisapride and magnesium, and allowing free fluid intake on evening of surgery, among numerous other inter ventions instituted. They described a median postoperative stay of 2 days, mobilization of patients for 5 hours on second post- operative day and 10 hours on third postoperative day. They also showed decreased pain and fatigue scores.(43) Delaney et al. stud- ied 60 patients undergoing major abdominal and pelvic surgeries without administration of preemptive epidurals, oral cathartics, and prokinetic agents. They have described shorter length of stay than patients having traditional care.(46) Recent developments of laparoscopic colon surgery showed significant improvements in average length of stay after colec- tomy and also better patient satisfaction in terms of pain control. This further catalyzed the interest in fast track pathways in colon and rectal surgery. Several authors described in their studies, multimodal care plans involving different strategies to optimize preoperative, intraoperative, and postoperative limiting factors, to achieve an early discharge with no difference in readmission rate or mortality.(16, 17, 24, 42, 46–48) Wind et al. published a review of all randomized controlled and controlled clinical trial on fast track colon surgery. This meta-analysis showed that the average hospital stay (2.61 days) and morbidity were signifi- cantly lower for fast track programs.(44) The strategies adapted in these studies included the following: extensive preoperative counseling, no bowel preparation, no premedication, antibiotics administration before surgery, no preoperative fasting, adminis- tration of carbohydrate loaded liquids until 2 hrs before surgery, tailored anesthesia encompassing thoracic epidural anesthesia, and short-acting anesthetics, perioperative high inspired oxygen concentrations, avoidance of perioperative fluid load, short inci- sions, minimally invasive surgery, nonopiod pain management, no routine use of drains and nasogastric tubes, early removal of bladder catheters, standard laxatives and prokinetics, and early and enhanced postoperative feeding and mobilization. There are no randomized controlled trails comparing laparo- scopic, fast track, and standard approaches. However, recently LAFA (laparoscopic and or fast track multimodal management versus standard care) trial was instituted, which was conceived care paths and optimal postop management to determine whether laparoscopic surgery, fast track surgery, or a combination of both is to be preferred over open surgery with standard care in patients having segmental colectomy for malignant disease.(49) SUMMARY Care paths are tools which promote evidence-based standard care, improve efficiency, and reduce hospital stay without com- promising the quality of final outcome of care. Care paths can be used as either disease specific or process- specific tools to manage patients throughout the complete disease cycle. Care path development requires a dedicated multidisci- plinary team. 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BMC Surg 2006; 6: 16. 10 Limitations of anorectal physiology testing Thomas E Cataldo and Syed G Husain CHALLENGING CASE A 65-year-old woman and her 30-year-old daughter both present to your office with complaints of fecal incontinence. Both are G3 P3, all vaginal deliveries, and have had at least one delivery of a child of 8 pounds or more. Both have required an assistance device for delivery of one child. Both report fecal soiling for the last year. The older woman reports progressive uncontrolled passage of flatus and occasional identification of stool in her undergarments that she was unaware of having passed. The daughter reports incontinence to moderate amounts of stool despite attempts to delay defecation. There is additional incontinence associated with athletic activity. CASE MANAGEMENT Normal function of the anus and rectum resulting in comforta- ble passage of stool under voluntary control is a complex balance of a number of competing factors and requires intricate correct performance of enteric and colonic physiology, rectal, anal and pelvic sensory and motor nerves, as well as anatomically intact and functioning anal and pelvic musculature. Disruption of any of these factors may result in fecal incontinence. On the other end of the spectrum, the patient may suffer difficult, painful, or incomplete evacuation. Anorectal dysfunction is often devastating to the patient resulting in emotional distress and social isolation. Fecal continence is defined as the ability to defer defecation until a socially appropriate time and place. Incontinence has a number of definitions from simply involuntary passage of stool to inability to control passage of solid, liquid, or gas. In a 2001 consensus conference report fecal incontinence is defined as, “recurrent uncontrolled passage of fecal material for at least one month in an individual with a developmental age of at least four years”.(1) Reported prevalence varies from 1.4% to 18%, with rates as high as 45% in elderly, debilitated, or psychiatrically impaired institutionalized adults. These numbers are generally accepted as under reported due to patients’ unwillingness to come forward due to associated social and cultural stigma.(1–3) Constipation is as difficult to define. It may be as subjective as any difficulty or infrequency in passing stool as perceived by the patient. The Rome II criteria define constipation as two or more of the following for at least 3 months: straining more than 25% of the time, hard stools more than 25% of the time, incomplete evacuation more than 25% of the time, two or fewer bowel move- ments in a 7 day period.(4) A problem inherent to all anorectal physiology testing is the scarcity of “normal” values for comparison. There is relative paucity of literature describing anorectal physiology testing on normal population and almost all of the available studies are comprised of small group of subjects. PHYSIOLOGY OF FECAL CONTINENCE Normal fecal continence relies on a number of mechanisms. The first of which is normal enteral and colonic motility and fluid transport physiology resulting in manageable stool consistency. Stool consistency may be the most important characteristic that influences fecal continence.(5) Some patients may be continent to solid stool but not to liquid or gas. The rectum needs to maintain adequate reservoir capacity. In addition the rectum, anus, and pelvic musculature must have adequate ability to sense and differentiate the presence, of solid, liquid, and gas. Additionally, it is postulated that the vascular cushions or hemorrhoids create a controllable seal as a rectal “corpus cavernosum”. This is supported by the identifi- cation of leakage in some patients after otherwise uncomplicated hemorrhoidectomy.(5) On a mechanical level, defecation occurs when the pressure within the rectum exceeds the pressure or resist- ance provided by the anus. For normal defecation this relies on the controlled increase in rectal pressure combined with simultaneous relaxation of the anus and straightening of the rectum through relaxation of the pelvic muscles. The rectum must also possess cor- rect mechanical properties of capacity and distensibility. It must be able to sense the need to empty and the qualities of the contents within it. Disease processes or injuries that limit the ability of the rectum to distend to accept stool and air from the sigmoid colon will alter the urge to defecate, and the ability to defer defecation. Conversely, a chronically distended capacious rectum may lose the ability to sense when it is full and thereby overflow. Both cases might present as incontinence. Alternatively, if the body cannot differenti- ate between solid, liquid, or gas or if the mechanism by which this is sampled is altered, the result is often fecal soiling. THE ANORECTAL PHYSIOLOGY LAB A battery of devices and tests has been developed to investigate many aspects of normal and altered defecation. Many centers have collected the equipment to accomplish these tests. (Figure 10.1). Much work remains to fully elucidate the source and thereby the solutions to disordered defecation. INVESTIGATIONS FOR INCONTINENCE Manometry Manometry is a technique to measure the pressures which exist within the anal canal and the pressures that the anus is capable of achieving voluntarily. Over many years a variety of catheters, pressure detectors, and recording apparatuses have been devel- oped. In addition, different operator techniques have been devel- oped making standardization of results difficult. Throughout the 1960s a variety of catheters were developed with different num- bers of open tipped channels and microballoons. The number of channels varied and they were arranged radially or in a spi- ral orientation. Water within the channels was either static or continuously perfused. Initial continuous recordings were made with pen and ink on polygraph devices. Currently, the state of the art manometers contain solid state micropressure transducers mounted within the catheter itself (Figure 10.2a,b). In addition . care. CARE PATHS IN COLON AND RECTAL SURGERY Care paths in surgery are used in the management of patients under- going commonly performed surgical procedures.(15) In colon and rectal surgery, care. care. improved outcomes in colon and rectal surgery DEFINING AND IMPROVING OUTCOME MEASURES Surgical care outcomes have been defined by a variety of measures. Complication rates relating to. explicit and well-defined standards for care. They support introduction of evidence-based medicine and use of clini- cal guidelines thus reducing variations in patient care and improving clinical outcomes. (27)