Clinical Outcomes and Cost Analysis of a “Fast Track” Postoperative Care Pathway for Ileal Pouch-Anal Anastomosis. A Case Control Study

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Abstract
Purpose: Traditional length of hospital stay after ileal pouch-anal anastomosis is 8 to 15 days. Fast track rehabilitation programs reduce stay, but there are concerns that readmission and complication rates may be increased. This study evaluated a fast track pathway after ileoanal pouch surgery. Methods: One hundred three consecutive patients underwent ileal pouch-anal anastomosis on two colorectal services using a fast track protocol with early ambulation, diet, and defined discharge criteria. Direct hospital costs and 30-day and long-term complication data were collected. Patients were matched to controls managed with traditional care pathways by other colorectal staff. Results: Matching was established for 97 patients. Fast track patients had shorter hospital stay than controls (median 4vs.5 days; mean 5.0vs.5.9,P= 0.012). Readmission and recurrent operation rates were similar (24vs.20 percent,P= 0.49, and 9vs.10 percent,P= 0.8, fast trackvs.control, respectively). Median direct costs per patient (US$) within 30 days were lower with fast track (5692vs.6672,P= 0.001), primarily because of reductions in postoperative management expenses. Complication rates, including pouch failure, bowel obstruction, pouchitis, and anastomotic stricture were comparable. Early discharge (≤ 5 days from surgery) occurred in 79 (77 percent) fast track patients. Failure with early discharge was associated with male gender, reoperations, and anastomotic complications. Conclusions: Fast track protocol after ileoanal pouch surgery reduces length of stay and hospital costs without increasing complication rates. Successful early discharge usually signals a benign postoperative course.