Principles of fast-track surgery
Henrik Kehlet, Prof., MD, PhD
Section for Surgical Pathophysiology, 4074, Rigshospitalet Copenhagen University
Telephone: +45 3545 4074
Fax: +45 3545 6543
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Short Title: Multimodal perioperative rehabilitation programmes
Key words: fast-track surgery, pain, fluid therapy, perioperative care, minimal invasive surgery
Abstract
Recent evidence has documented that a combination of single-modality evidence-based care principles into a multimodal effort to enhance postoperative recovery (the fast-track methodology) has led to enhanced recovery with reduced medical morbidity, need for hospitalisation and convalescence. Nevertheless, general implementation of fast-track surgery has been relatively slow despite concomitant economic benefits. Further improvement in postoperative outcome may be obtained by developments within each care principle with a specific focus on minimal invasive surgery, effective multimodal, non-opioid analgesia and pharmacological stress reduction.
Despite progress in perioperative care over the last decade, surgical injury is still often followed by pain, nausea, vomiting, ileus, stress-induced organ dysfunction (pulmonary, cerebral, cardiovascular), fatigue and catabolism, all of which may contribute to morbidity, need for hospitalisation and prolonged convalescence. Since the postoperative recovery process includes multiple pathogenic mechanisms, an enhanced postoperative recovery programme (the fast-track methodology) has been developed as a stepwise multimodal effort by combining single-modality evidence-based interventions. The concept was introduced more than 10 years ago and subsequently been demonstrated to provide a powerful instrument to enhance recovery and reduce morbidity across almost all surgical procedures from simple day case procedures to more complex surgeries7, 10, 12, 14, 17.
In the following, a short update on developments within specific perioperative interventions will be outlined, while the results of the procedure-specific data are presented in other chapters. The fast-track methodology includes 3 perioperative phases: pre-, intra- and postoperatively.
Preoperatively
It is well documented that optimisation of preoperative organ dysfunctions may reduce postoperative morbidity14. Such interventions also include abstinence from alcohol14, 17 and smoking25. The specific role of preoperative exercise programmes to optimise postoperative recovery remains debatable, although rational. Recently, there has been a focus on optimisation of fluid balance, especially to compensate for preoperative dehydration. The most well-documented principle is stroke-volume optimisation with small amounts of colloids13 with well-documented outcome benefits. The classical concept of preoperative bowel clearance has now been questioned and several randomised trials and systematic reviews have shown it to be unnecessary or even to increase morbidity, especially in colorectal procedures17, and therefore should be avoided. In experimental and clinical studies a pre-injury carbohydrate load has been demonstrated to improve outcome and to have anti-catabolic effects24 and several clinical studies have suggested a clinical advantage by a preoperative carbohydrate load given in the evening and morning before the operation. However, more procedure-specific studies are required to define indications before general recommendations can be made, since the data are not entirely conclusive17.
A key point in the fast-track methodology is preoperative information and psychological preparation of the patient. This must be done in good time before the operation, and preferably to include the relatives. In this process, the patient is informed in detail about the perioperative care programme and in which parts the patient will be required to actively participate (oral nutrition and mobilisation).
Intraoperatively
It is well-established to avoid hypothermia, which otherwise will increase cardiac and wound morbidity as well as risk of bleeding complications17. Intraoperative fluid management is again crucial since an unnecessary fluid overload is well documented to increase postoperative morbidity3, 4. Modern principles of perioperative fluid management, especially in high-risk patients, therefore include strict observation on fluid administration and losses in order to avoid hypovolemia and a fluid excess21 – and in certain high-risk groups combined with the principles of goal-directed fluid management13.
The concept of minimal invasive surgery is well established to reduce pain and inflammatory responses to surgery, thereby reducing morbidity and enhancing recovery. However, much more data are required when minimal invasive surgery is combined with the fast-track methodology in order to obtain the full benefits of minimal invasive surgery15. So far, very few, randomised and blinded studies are available and only in certain operations17. It is a key point in fast-track programmes to establish a close collaboration between surgeons and anaesthesiologists, since the anaesthesiologist controls several important components such as stress- and pain-reducing regional anaesthetic techniques and modern principles of non-opioid or opioid-reducing anaesthesia and analgesia which have well-documented major implications for postoperative recovery26, 27.
Postoperatively
The postoperative care may often be complicated and confounded by continuing use of old-fashioned non-documented principles of care which may reduce recovery. This includes unnecessary use of naso-gastric tubes, use or prolonged use of drains, urinary catheters, restrictions, etc.7, 10, 12, 14, 17, calling for updated adjustment of such principles into the enhanced recovery programmes.
Sufficient postoperative analgesia is a prerequisite for optimised recovery and includes evidence-based, opioid-sparing, multimodal analgesia, and preferably regional anaesthetic techniques where appropriate26, 27. More recently, there has been a focus on peripheral continuous administration of local anaesthetics into the wound5, 16, 20 and where the results so far have been promising without increased risk of local wound complications. Altogether, perioperative pain management must be based on procedure-specific evidence22, since pain-intensity and consequences on organ function as well as efficacy and side-effects of different analgesics are different.
One of the basic pathogenic mechanisms of postoperative morbidity is surgical stress responses (endocrine, metabolic and inflammatory) which may increase demands on body organs, thereby increasing the risk of organ dysfunction and morbidity. The key methods to reduce such responses include regional anaesthetic techniques, minimal invasive surgery14, 17 and more recently pharmacological stress reduction with glucocorticoids, statins, insulin, beta-blockade and anabolic agents, again on a procedure-specific basis1, 2, 8, 9, 17, 19, 28. However, the principles and potential of pharmacological reduction of stress responses are still under investigation, not allowing final conclusions1, 2, 8, 17, 19, 28. The role of intra- and early postoperative oxygen supplementation is rational since hypoxaemia and impaired pulmonary function are well known surgical stress responses – and with potential side effects on the brain, cardiac and wound function. Nevertheless, the topic is still debatable17, 23 calling for further studies on dose and duration of oxygen supplementation.
Postoperative paralytic ileus is a main factor to delay recovery in certain operations due to limited oral intake and discomfort, nausea, vomiting and risk of pulmonary morbidity11. However, much evidence has appeared over the last couple of years leading to effective principles for prevention or reduction of ileus, thereby reaching conventional discharge criteria much earlier than before. Evidence-based principles for reduction of paralytic ileus include continuous thoracic local anaesthetic epidural analgesia, avoidance of a fluid excess and use of opioids. Oppositely, use of laxatives, chewing gum or peripheral opioid antagonists (if opioids are used) have been demonstrated to reduce ileus. Importantly, routine use of nasogastric tubes should be avoided and early oral nutrition instituted11. Many studies have shown that such interventions will reduce ileus from about the usual 4-5 days to less than 2 days in colorectal procedures11. In addition, effective anti-nausea and vomiting treatment is essential for fast-track recovery and where the multimodal evidence is well documented to include serotonin-antagonists, low-dose dexamethasone, droperidol and propofol for intravenous anaesthesia6.Subsequently, these nausea, vomiting and ileus reducing therapies will allow early oral nutrition which otherwise has been shown to be safe and potentially to reduce infectious complications18. Obviously, the above-mentioned interventions should be utilised for early postoperative mobilisation which again otherwise may reduce catabolism, loss of muscle mass and function and risk of thromboembolic complications – although, hard scientific documentation for these benefits are not available. Finally, these combined efforts may reduce the traditional complaints of late postoperative fatigue29.
Future strategies
The all-over clinical benefits of the fast-track methodology are well-documented across several procedures10, 12, 17 as further documented in the following specific chapters. Nevertheless, there is a severe need for enhanced implementation of such fast-track programmes, since several surveys have shown a slow acceptance and implementation of the evidence10, 12, 17. Also, there should be a focus on other aspects of perioperative care when the fast-track methodology and enhanced recovery are obtained, such as the need for prolonged thromboembolic prophylaxis. Further development of the minimal invasive surgery concept as well as pharmacological stress reduction will undoubtedly lead to further improvements. Subsequently, the economic consequences will require further assessment. Again, all studies should be done on a procedure-specific basis since each operation has its own characteristics of perioperative pathophysiology and risks of surgical and medical morbidity. Finally, there is a severe need for studies in acute surgeries where morbidity continues to be high – and where implementation of the concept of the fast-track methodology may be expected to lead to major improvements.
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