the primary goal of all surgery recovery programs is to reduce hospital stay and to quickly restore the overall well - being of the patient with a reduced complication rate . many advances have been developed to reach this goal , including all 3 parameters : preoperative , intraoperative , and postoperative measures . the advancement of minimally invasive surgical techniques , such as laparoscopic surgery , has been shown to accelerate patient recovery , reduce postoperative pain and fatigue , and decrease the length of hospital stay . according to the color ( colon cancer laparoscopic open resection ) trial , laparoscopic colon resection results in earlier recovery of bowel function , decreased need for analgesia , and shorter hospital stay as compared to open colectomy . additional advantages associated with laparoscopic colon surgery include improved pulmonary function and overall quality of life postoperation . in 1995 , ( ft ) rehabilitation as an approach to further pronounce the advantages of minimally invasive surgery , by reducing the physiologic adjustment induced by traditional surgical methods . the mainstay of ft protocols include avoidance of nasogastric ( ng ) tube and preoperative bowel cleansing , appropriate analgesia , early oral feeding and ambulation , as well as well - controlled fluid balance . using a ft rehabilitation care plan for laparoscopic colon resection , length of hospital stay could have been reduced to 2 to 3 days . when compared with non - ft laparoscopic right hemicolectomy , patients who underwent ft protocol resumed normal gastrointestinal function earlier and observed a decrease in postoperative morbidity , providing evidence that ft rehabilitation directly enhances the overall recovery of patients . a recent meta - analysis showed a reduction in overall complications , but major complications were not reduced with ft rehabilitation . thus , enhanced recovery seems safe , but the quality of trials and lack of sufficient outcome parameters do not justify its implementation as the standard of care for laparoscopic colorectal surgery . it has been in play for over 10 years now , yet there still is no agreement on a precise , standardized protocol for laparoscopic colorectal surgery . the aim of this study is to provide data supporting the use of ft rehabilitation care plans in laparoscopic colorectal surgery , to present our protocol , and to share our experience with it . after obtaining the institutional review board approval , we performed , between the years 2007 and 2010 , a prospective study including patients who underwent laparoscopic colorectal resection in accordance with the guidelines of our ft rehabilitation protocol . this is a single general surgeon series ( am ) , with an extensive experience in laparoscopic surgery . prior to patient enrollment in the study , each participant had a thorough discussion of the nature of the surgery as well as details of the pre- , peri- , and postoperative parts of the ft care plan . exclusion criteria included emergent surgery or patients who underwent combined surgery requiring resection of multiple organs that may limit the use of our ft care plan . conversions to open surgery were excluded as well . of note , all cases that required a substantial incision , the ft rehabilitation plan allows for early return to routine activity and early resumption of gastrointestinal activity , which resulted in fast recovery and earlier discharge from the hospital . elements reflective of the ft care plan being measured include time to removal of ng tube and urinary catheter , time to fluid and food intake , time to bowel function , need for pain control , and length of hospital stay . data collected included patients ' characteristics , indication for surgery , and type of surgical procedures . recovery parameters and variables pertaining to the ft rehabilitation plan ( ie , first bowel movement , time to fluid and diet resumption , and time to patient discharge ) were recorded . early postoperative morbidity ( ie , postoperative ileus [ defined as lack of flatus or bowel movement within 5 postoperative days or vomiting requiring reinsertion of ng tube ] , wound infection , intra - abdominal abscess or leak , urinary tract infection , cardiopulmonary complications , and hemorrhage ) were also studied . patients were informed extensively about our ft surgery care plan and our goal of early discharge . the department , including all staff and nurses , were educated about ft rehabilitation care plan to ensure quality control . intravenous antibiotic prophylaxis ( ceftriaxone 1 g and metronidazole 500 mg ) was given 30 minutes prior to surgery and continued for 24 hours afterward ( ie , 2 extra doses of metronidazole 500 mg ) . pneumoperitoneum was achieved by veress needle , and port placement varied consistently depending on the segment of colon to be resected . after induction of anesthesia , a urinary catheter and an ng tube were inserted in all patients . fluid maintenance was limited to 1 l of crystalloids , except for patients who experienced hypotensive episodes where extra fluid boluses ( 300 cc ) were administered . patient position was determined based on the resected segment . after standard recovery at the postanesthesia unit , all patients were transferred to a regular nursing floor . analgesia was maintained by use of oral nonsteroidal anti - inflammatory medications ( ie , ibuprofen , celecoxib ) and oral hydrocodone if necessary ; no patient - controlled analgesia pumps were used . for nausea , on postoperative day ( pod ) 1 , the patient was reassessed and the care plan was discussed again . in addition , oral fluid intake was initiated . on pod 2 , regular hospital meals fluid maintenance ( 100 cc / hour saline ) was discontinued if patients tolerated a liquid meal . on pod 3 , evaluation of patient status was performed and discharge was approved for stable and mobile candidates who tolerated a liquid diet . categorical variables were summarized as frequency ( percentage ) , and quantitative variables as mean sd , and median ( minimum ; 25% ; median ; 75% ; maximum ) . patients were informed extensively about our ft surgery care plan and our goal of early discharge . the department , including all staff and nurses , were educated about ft rehabilitation care plan to ensure quality control . intravenous antibiotic prophylaxis ( ceftriaxone 1 g and metronidazole 500 mg ) was given 30 minutes prior to surgery and continued for 24 hours afterward ( ie , 2 extra doses of metronidazole 500 mg ) . pneumoperitoneum was achieved by veress needle , and port placement varied consistently depending on the segment of colon to be resected . after induction of anesthesia , a urinary catheter and an ng tube were inserted in all patients . fluid maintenance was limited to 1 l of crystalloids , except for patients who experienced hypotensive episodes where extra fluid boluses ( 300 cc ) were administered . after standard recovery at the postanesthesia unit , all patients were transferred to a regular nursing floor . analgesia was maintained by use of oral nonsteroidal anti - inflammatory medications ( ie , ibuprofen , celecoxib ) and oral hydrocodone if necessary ; no patient - controlled analgesia pumps were used . for nausea , on postoperative day ( pod ) 1 , the patient was reassessed and the care plan was discussed again . in addition , oral fluid intake was initiated . on pod 2 , regular hospital meals fluid maintenance ( 100 cc / hour saline ) was discontinued if patients tolerated a liquid meal . on pod 3 , evaluation of patient status was performed and discharge was approved for stable and mobile candidates who tolerated a liquid diet . categorical variables were summarized as frequency ( percentage ) , and quantitative variables as mean sd , and median ( minimum ; 25% ; median ; 75% ; maximum ) . over a 4-year time span , 88 patients underwent elective colon or rectal surgery by the 2 surgeons . seventy - one patients agreed and underwent ft rehabilitation care plans for laparoscopic colorectal surgery . forty - one patients were male and 30 were female , with mean age of 60  16 years ( table 2 ) . indication for surgery was colorectal cancer in 45 patients ( 64% ) , diverticular disease in 9 patients ( 12.5% ) , malignant colonic polyps in 9 patients ( 12.5% ) , and inflammatory bowel disease in 8 patients ( 11% ) ( table 2 ) . the surgical procedures were right hemicolectomy in 21 patients ( 30% ) , left hemicolectomy or sigmoidectomy in 12 patients ( 17% ) , anterior resection in 19 patients ( 27% ) , total colectomy in 4 patients ( 5.5% ) , subtotal colectomy in 3 patients ( 4% ) , hartmann reversal in 8 patients ( 11% ) , and abdominoperineal resection in 4 patients ( 5.5% ) ( table 2 ) . patients , indication for surgery , and type of operations abbreviation : asa , american society of anesthesiology score . almost all patients were encouraged to and succeeded in handling oral fluid intake on pod 1 . forty - five patients fulfilled the ft care plan criteria and were discharged on pod 3 . failure to follow the ft care plan and early discharge was in general related to postoperative complications or administrative repositioning limitations . becuase neither flatus nor defecation were criteria for discharge , it was not possible to calculate an accurate incidence rate . however , of the 35 patients who experienced flatus or defecation prior to discharge , it occurred on pod 2  0.4 and pod 3  0.8 , respectively . of note , in terms of pain control , all 35 patients were satisfied with the protocol oral analgesics . . there were 6 patients with complications : 1 patient experienced superficial surgical site infection ( 1.5% ) , 1 intra - abdominal abscess ( 1.5% ) , 2 had postoperative ileus ( 2.8% ) that required reinsertion of ng tube , and 1 has a gastrointestinal hemorrhage ( 1.5% ) that was treated with blood transfusion . the patient with the wound infection was treated with antibiotics and local wound care , while the intra - abdominal abscess required ultrasound - guided drainage . three patients ( 4% ) were readmitted for diarrhea , fever without definitive etiology , and acute cholecystitis . all published results of ft rehabilitation care plans have shown comparable outcomes . specifically , rapid patient recovery , decreased postoperative fatigue and ileus , and patient discharge within 2 to 5 days following surgery have been reported . the most significant impact of the ft rehabilitation care plans is the reduction of postoperative morbidity from > 20% to 9.1% when compared with traditional care plans . our study shows comparable results with current literature , providing further evidence that ft rehabilitation is an applicable method for recovery programs to be used in laparoscopic colorectal surgery . our protocol for operative management included no mechanical bowel preparation , avoidance of ng tube , appropriate anesthesia and pain control , early ambulation , and oral intake of fluids and solid foods . in addition , we made an effort to tightly control fluids intraoperatively to reduce sequelae of fluid overload . we wanted to illustrate that mandatory return of bowel function prior to discharge does not play any significant role in either treatment and/or postoperative complications in ft rehabilitation . our results provide significant evidence that patients do not experience greater morbidity when discharged prior to return of normal bowel function . approximately 50% of our patients were discharged prior to flatus passage or defecation , which agrees well with previous reports , and yet no increased report of complications . for sheer completeness , we presented data of patients that experienced bowel function prior to discharge . mechanical bowel preparation has not only been shown to be unnecessary , but rather increases the risk of anastomotic dehiscence and spillage , consequently leading to higher infectious complications rate . spillage occurs 3 more frequently for liquid bowel content than for semisolid contents and very rarely in solid bowel content . moreover , in 1 study , patients receiving mechanical bowel preparation had increased incidence of bowel content spillage when compared with patients who did not : 17% versus 12% , respectively . in our study a survey showed that 66% and 41% of european and united states surgeons , respectively , leave the ng tube in situ after surgery . however , there is no evidence supporting its use because it may be associated with increased complications as well as patient discomfort . we have reason to believe that early removal of the ng tube induces early feeding , which has multiple advantages . early feeding has been shown to maintain absorptive integrity of the bowel , to increase collagen content in the anastomosis , to allow positive nitrogen balance with reduction of insulin resistance , to favor wound healing , and to reduce risk of sepsis . fluid maintenance is strictly followed in our protocol . to prevent any symptoms of fluid overload further fluids were administered as needed , based on the patients ' hemodynamic status . those were rarely required . tight fluid control may prevent cardiopulmonary complications such as atelectasis , dyspnea , and oxygenation defects within the lungs due to fluid accumulation . fluid overload has been associated with cardiopulmonary complications , decreased muscular oxygen tension , and a delay in recovery of gastrointestinal function . our fluid maintenance protocol was feasible , and easily followed by the anesthesia and the departmental staff . anesthesia and pain control has a significant impact on postoperative complications and patient overall recovery . our protocol excluded the use of epidural catheters due to increased risk of urinary retention , ultimately postponing discharge from the hospital . this decreased risk of urinary retention allows for early removal of the urinary catheter , which is critical for early ambulation . ambulation , in turn , is key for accelerating the recovery period for patients because it induces a stimulant for return of normal gastrointestinal function . in addition , early ambulation is directly correlated to a decrease in risk of pulmonary and thromboembolic complications as well as preservation of muscle mass and function . in this prospective cohort study , despite the lack of a control group , we believe that our results illustrate reliable evidence that the ft rehabilitation care plan for laparoscopic colorectal surgery results in short hospital stay as well as low morbidity and mortality rates . herein , we have shown comparable outcomes related to our ft protocol as compared to traditional laparoscopic colorectal resection outcomes . a standard protocol for ft rehabilitation has yet to be developed ; however , we believe our protocol has shown to be successful in accelerating patient recovery , and , importantly , it is easily applicable and accessible to the average surgeon . despite the amount of research needed to perfect the management of ft rehabilitation , there exists strong clinical evidence that it indeed accelerates patient recovery with decreased incidence of morbidities and mortality .
background : fast - track ( ft ) rehabilitation protocols have been shown to be successful in reducing both hospital stay and postoperative complications , as well as enhancing overall postoperative patient recovery . 
 we are reporting the outcomes of our first group of patients undergoing colorectal surgery following the ft protocol.patients and methods : we performed a prospective study of patients , between january 1 , 2007 and january 31 , 2010 , who underwent laparoscopic colorectal resections in accordance with the guidelines of ft rehabilitation protocol . 
 recovery parameters including time to removal of naso - gastric tube and urinary catheter , time to bowel function and to resume diet , and length of hospital stay were evaluated . 
 postoperative outcomes , that is , postoperative complications and mortality , reoperations , and readmissions were also studied.results:a total of 71 patients , 30 women and 41 men , underwent ft rehabilitation for laparoscopic colorectal surgery . 
 the mean age of the patients was 60  16 years . 
 the most common surgical procedures were right hemicolectomy 30% and anterior resection 27% . 
 liquid and regular diet were initiated on postoperative day 1.2  0.4 and 2.1  0.4 , respectively . 
 overall postoperative morbidity was 8.5% . 
 the mean length of stay was 4.4  1.7 days , with only 3 readmissions . 
 forty - five patients fulfilled the ft care plan and were discharged on postoperative day 3 . 
 no reoperations or mortality were observed.conclusions:ft rehabilitation results in favorable postoperative outcomes . 
 our data provides evidence and suggests that ft protocols should be implemented as a reliable method of preparation and recovery for laparoscopic colorectal surgery .