Friday, 18 April 2014

Fast-track surgery. A new revolution after laparoscopy?

In the 90s, two different groups of surgical professionals developed new strategies aimed at improving the postoperative outcome of colon or rectal surgery patients. On the one hand, a group led by Dr. Kehlet from Scotland proposed different measures pre and post operatory while in Cleveland, another group led by Dr. Delaney focused his studies on postoperative models of introduction of an oral diet and early mobilization. Note that these new guidelines were not based on innovative technologies, but what they wanted was to simply lessen the suffering of the sick taking care to accomplish a combination of essential elements: better informed patients on the overall process, stress reduction, decreased pain, exercise as soon as possible, etc (Kehlet 1997).

In 2001, the same Dr. Kehlet led the group ERAS (Enhanced Recovery After Surgery), which coordinated several units of colo-rectal surgery in the Nordic European countries. ERAS developed 17 strategies, all evidence based with the intent to promote activities ranging from the politics of patient’ preparation to the process’ evaluation and outcomes (Fearon 2005).


Subsequently several systematic reviews and a meta-analysis have demonstrated the success of the ERAS program, also known as fast-track multimodal rehabilitation or (multimodal rehabilitation), which managed to obtain a significant reduction in the average hospital stay without increasing readmissions (Varadhan 2010).



Local experiences

I have detected two prospective cohort studies, one in the Hospital del Mar in Barcelona (Gil- Egea 2008), with 231 cases in fast-track and 134 in traditional mode, and an one ulterior Hospital Clinico de San Carlos in Madrid (Esteban 2012) with 108 cases in fast-track and 147 in control. In both studies, the observed reductions in average length of stay for patients in fast-track program have been significant with a range of reduction that has gone from 3 to 6 days.

Fast -track: a multimodal regimen that reduces suffering and improves results

Below you can see an updated summary of the main measures involved in the application of fast-track in colorectal surgery. As you can observe, these are simple guidelines, without any hidden surprises. I believe, however, that we only have to look at the difficulties of coordinating multidisciplinary actions to find any novelty: 
  • Inform the patient in the overall process, including the forecast of admission and engage him in decisions
  • Promote bowel function preservation measures
  • Avoid the medications that slow down the intestines
  • Preserve body temperature during surgery
  • Avoid catheters
  • Set the hydrotherapy
  • Anesthetize with epidurals
  • Use minimally invasive surgical techniques
  • Avoid opium based analgesics
  • Prevent nausea and vomiting
  • Remove catheters as soon as possible
  • Start oral feeding and ambulation at an early stage

Discussion

I want to stress that we should celebrate the innovation of the fast-track from various points of view. Firstly because for the first tests of the new methodology, a complex surgical procedure such as surgery of the colon and rectum usually with a tumour substrate in elderly patients with postoperative dysfunctions, has been chosen.

As a second reason, I think it's fair to point out how in a mainstream initiative, neither funders nor hospital owners have intervened. As much as we try to explain it, behind the fast-track we only find professional surgical groups motivated to see if things can be done better, if the guidelines are met and if the postoperative stages may be more comfortable and safer for the patients.

And finally, as a third point, I want to stress the fact that innovation is possible without large investments or major technologies. As demonstrated by the promoters of the fast-track doctors, if things are carried out in a more convenient and coordinated manner, the results can be significantly better.

And with that, all that’s left for me is to adhere to the views expressed by Dr. Karem Slim in the editorial of the journal Colorectal Disease (Slim 2011), which inspired the title I chose for this post, more specifically to the point that Dr. Slim makes, that probably the revelation that fast-track model procedures applied to all the surgical procedures will be the next best surgical revolution after laparoscopy.

Bibliography

Kehlet H. Multimodal approach to control postoperative pathophysiology and Rehabilitation. Br J Anaesth 1997; 78:606-17.

Fearon KC, Ljungqvist O, Von Meyenfeldt et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24:466-77.

Varadhan KK, Neal KR, Dejong CHC, et al. The enhanced recovery after surgery (ERAS) Pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomized controlled trials. Clin Nutr 2010; 29:434-40.

Gil-Egea MJ, Martínez MA, Sanchez M, et al. Rehabilitación multimodal en cirugía colorrectal electiva. Elaboración de una vía clínica y resultados iniciales. Cir Esp 2008; 84:251-5.

Esteban F, García M, Sanz R, et al. Resultados de la implantación de un protocolo de fast-track en una unidad de cirugía colorrectal: estudio comparativo. Cir Esp 2012; 90:434-9.

Slim K. Fast-track: the next revolution in surgical care following laparoscopy (Ed.) Colorectal Disease 2011; 3:478-80. 



Jordi Varela 
Editor

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