8
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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
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80. Miller G, Boman J, Shrier I, Gordon PH. Readmission for
small-bowel obstruction in the early postoperative period:
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81. Beck DE, Opelka FG, Bailey HR, Rauh SM, Pashos CL. Incidence
of small-bowel obstruction and adhesiolysis after open colorec-
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82. Senagore AJ. Pathogenesis and clinical and economic con-
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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-
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colorectal resection for cancer. Ann Surg 2007; 245(6): 867–72.
85. Bradshaw BG, Liu SS, Thirlby RC. Standardized periopera-
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surgery. J Am Coll Surg 1998; 186(5): 501–6.
86. Fukuya T, Hawes DR, Lu CC, Chang PJ, Barloon TJ. CT
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1499–507.


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

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

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

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


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

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)

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

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

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

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. With increasing popularity of laparoscopic colon
surgeries and other techniques to decrease perioperative stress
response, care paths in colon and rectal surgery are evolving
continuously, into new programs, such as fast-track surgery.
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1. Campbell H, Hotchkiss R, Bradshaw N, Porteous M.
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4. Delaney CP, Fazio VW, Senagore AJ et al. ‘Fast track’ postop-
erative management protocol for patients with high co-mor-
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surgery. Br J Surg 2001; 88: 1533–8.
5. Hendry P, Fearon KCH. Intraoperative surgical consider-

improves physical performance, pulmonary function and
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18. Edwards SG, Thompson AJ, Playford ED et al. Integrated
care pathways: disease-specific or process-specific? Clin Med
2004; 4: 132–5.
19. Melbert RB, Kimmins MH, Isler JT et al. Use of a critical
pathway for colon resections. J Gastrointest Surg 2002; 6:
745–52.
20. Archer SB, Burnett RJ, Flesch LV et al. Implementation of a
clinical pathway decreases length of stay and hospital charges
for patients undergoing total colectomy and ileal pouch/anal
anastomosis. Surgery 1997; 122: 699–703.
21. Pearson SD, Goulart-Fisher D, Lee TH. Critical pathways as
a strategy for improving care: problems and potential. Ann
Intern Med 1995; 123: 941–8.
22. Stephen AE, Berger DL. Shortened length of stay and hos-
pital cost reduction with implementation of an accelerated
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23. Cheatham MLMD, Chapman WCMD, Key SPMDa, Sawyers
JLMD. A meta-analysis of selective versus routine nasogastric
decompression after elective laparotomy. Annals of Surgery
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24. Khoo CK, Vickery CJ, Forsyth N, Vinall NS, Eyre-Brook IA.
A prospective randomized controlled trial of multimodal peri-
operative management protocol in patients undergoing elective
colorectal resection for cancer. Ann Surg 2007; 245: 867–72.
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learning from experience. Nurs Manag (Harrow) 2005; 12: 28–31.
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R. Care after colonic operation–is it evidence-based? Results
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42. Gatt M, Anderson AD, Reddy BS et al. Randomized clinical trial
of multimodal optimization of surgical care in patients under-
going major colonic resection. Br J Surg 2005; 92: 1354–62.
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moidectomy with a multimodal rehabilitation programme.
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44. Wind J, Polle SW, Fung Kon Jin PH et al. Systematic review of
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domized, controlled trial between a pathway of controlled
rehabilitation with early ambulation and diet and traditional

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)

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