Clinical review

Management of patients in fast track surgery

Douglas W Wilmore, Frank Sawyer professor of surgery ^a, Henrik Kehlet, professor of surgery ^b. 

^a Laboratories for Surgical Metabolism and Nutrition, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02215, USA, ^b Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark

Correspondence to: D Wilmore dwilmore{at}partners.org

Surgery is slowly undergoing revolutionary changes due to newer approaches to pain control, the introduction of techniques that reduce the perioperative stress response, and the use of minimally invasive operations. Subsequently, many surgical procedures (such as arthroscopic surgery, laparoscopic cholecystectomy, eye surgery, sterilisation procedures, herniorrhaphy, and cosmetic operations) are routinely performed on an outpatient basis. Recently published pilot studies suggest that when these newer approaches are used in patients undergoing more complex elective surgical procedures, postoperative complications can be reduced, length of hospital stay decreased, and time to recovery shortened. This review of recent advances made in this newly developing specialty of fast track surgery will emphasise techniques that facilitate early recovery after major surgical procedures.

	What is fast track surgery?

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Fast track surgery combines various techniques used in the care of patients undergoing elective operations. The methods used include epidural or regional anaesthesia, minimally invasive techniques, optimal pain control, and aggressive postoperative rehabilitation, including early enteral (oral) nutrition and ambulation. The combination of these approaches reduces the stress response and organ dysfunction and therefore greatly shorten the time required for full recovery.

Recent advances in understanding perioperative pathophysiology have indicated that multiple factors contribute to postoperative morbidity, length of stay in hospital, and convalescence (fig 1). Major improvements in surgical outcome may therefore require multifaceted interventions (fig 2). Ambulatory surgery has become routine for many procedures with a well documented record for safety and low morbidity, even in patients at high risk. ^{1 2} Studies of fast track surgery have evaluated somewhat similar approaches toward larger operations which carry more risk (box). Preliminary results from predominantly non-randomised trials have been positive (table). These studies have included high risk elderly patients undergoing operations such as segmental colonic resection, prostatectomy, and aortic aneurysmectomy. These preliminary data indicate topics for further randomised trials; the data need to be confirmed and extended to include end points of reduced costs, preserved safety, and patient satisfaction.

View larger version (17K): [in this window] [in a new window]   Fig 1.   Factors contributing to postoperative morbidity

View larger version (24K): [in this window] [in a new window]   Fig 2.   Interventions needed for major improvement in surgical outcome

We searched Medline from 1980 to the present and reviewed the articles identified. This information was supplemented with our own research on the mediators of the stress response in surgical patients, the use of epidural anaesthesia in elective operations, and pilot studies of fast track surgical procedures with the multi-faceted approach.¹²

	Preoperative evaluation and education

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Before any operation, including fast track surgery, organ function should be optimised for patients with cardiac disease, chronic obstructive lung disease, diabetes mellitus, and other disorders, according to current recommendations. Pharmacological means have been used to enforce abstinence in alcohol misusers, and this has resulted in lower morbidity and enhanced recovery in such patients.¹³ Prolonged (one to two months) cessation of smoking in the preoperative period should also be encouraged to reduce postoperative respiratory complications.

Education of patients about perioperative care before the operation reduces the need for pain relief,¹⁴ can include instruction on relaxation techniques which can be used after the operation, reduces anxiety, and improves outcome.¹⁵ Patients can access information on specific clinical procedures on www.facs.org/public_info/operation/aboutbroch.html, which is provided by the American College of Surgeons.

	Optimising anaesthesia

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Recent developments in techniques in anaesthesia have optimised conditions for surgeons to operate while allowing for very early recovery of vital organ function after major procedures. Thus, the introduction of rapid short acting volatile anaesthetics (for example, desflurane and sevoflurane), opioids (for example, remifentanil), and muscle relaxants have facilitated expansion of ambulatory surgery for minor to moderate procedures (see box). However, the same techniques may be used to facilitate early recovery and decreased need for prolonged monitoring and stay in recovery and high dependency wards after major procedures, although this issue has been less explored and documented than the use of such techniques for minor procedures.¹⁶ The use of anaesthetic techniques that provide for minimal carryover of opioid effects into the recovery period, supported by other non-opioid analgesic methods (see below), may minimise postoperative complications and facilitate recovery after major procedures.

Most, if not all, postoperative organ dysfunction and morbidity associated with major operative procedures may be related to changes induced by stress caused by the operation. Neural blockade techniques have been developed in recent years to provide attenuation of the surgical stress response, thereby reducing postoperative organ dysfunction and allowing early recovery.¹⁷

After experimental studies showed that the peripheral and central nervous system was crucial in the initiation of the endocrine-metabolic response to injury, a vast amount of research has shown that regional anaesthetic techniques that use local anaesthetics can reduce the classic pituitary, adrenocortical, and sympathetic responses to surgery.¹⁷ Neurogenic blockade (either by administering a local anaesthetic in the spinal or epidural space or by using local anaesthetic techniques that block the nerve impulses from an area) improves postoperative nitrogen economy and glucose intolerance but does not modify inflammatory or immunological responses. Relevant to clinical care, continuous neural blockade for 24 to 48 hours is necessary for a pronounced reduction in perioperative stress in major surgery.¹⁷ Moreover, the systemic effects of local or regional anaesthesia/analgesia on the stress response are greatest in procedures on the lower body (lower extremities or pelvis) compared with upper abdominal and thoracic operations. The effects of regional anaesthetic techniques are manifest by improved pulmonary function, decreased cardiovascular demands, reduced ileus, and improved pain relief.¹⁷ A recent meta-analysis of regional anaesthetic studies showed a 30% reduction in morbidity compared with general anaesthesia.¹⁸

	Operative techniques

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Minimal invasive surgery
The use of minimal invasive abdominal surgical techniques, such as laparoscopic cholecystectomy, have not reduced the early endocrine mediated metabolic response to surgery, but this approach has been associated with a decrease in various inflammatory responses and immunodysfunctions.¹⁹ Pulmonary function seems to be improved and postoperative ileus reduced with minimal invasive approaches. ^{19 20} Other studies have reported less pain, shorter hospital stays, and reduced morbidity, not only in abdominal surgery but also in cardiothoracic, vascular, cerebral, and major orthopaedic procedures. The scientific basis for these effects remains incompletely understood, and more basic studies are necessary to improve our understanding of the influence of minimal invasive surgery on postoperative responses.

Intraoperative normothermia
Operating rooms are cold. Patients are inadequately clothed and receive anaesthetics which hamper their homeostatic defences to cold. As a result, patients undergoing operations lasting over two hours often become hypothermic, with a fall of core temperature of 2-4°C. During rewarming cortisol and catecholamines are released, which augment the stress response of the operation.²¹ Keeping patients warm has been associated with a threefold decrease in the rate of wound infection, a reduction in operative blood loss, a decrease in untoward cardiac events, including ventricular tachycardia, and a reduction in nitrogen excretion and patient discomfort.²¹ Maintenance of a normal temperature during surgery is central to reducing the stress of the surgical procedure and reducing the risk of organ dysfunction.

	Postoperative care

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The first 24 hours
Nasogastric tubes should not be used routinely in patients undergoing elective gastrointestinal surgery. A large meta-analysis of 26 randomised trials concluded that routine use may, in fact, be detrimental by increasing the incidence of pneumonia and delaying early enteral feeding by nasogastric tube.²² Likewise, randomised trials of drains show little benefit after cholecystectomy, joint replacements, colon resection, thyroidectomy, and radical hysterectomy. ^{23 24} Drains limit formation of seroma after mastectomy, but such wound drainage does not limit discharge from hospital.

Nausea, vomiting, and ileus
The ability to resume a normal diet is essential for a successful fast track surgical programme after both minor and major procedures. Principles for rational prophylaxis and treatment of nausea and vomiting have been developed, ^{28 29} and several agents including droperidol, antiserotonergic drugs, and analgesic regimens with reduced use of opioid drugs will reduce these symptoms. The use of multifaceted regimens for nausea and vomiting in combination with dexamethasone requires further evaluation. Postoperative ileus, which is predominantly caused by a combination of inhibitory neural sympathetic visceral reflexes and the intestinal inflammatory response, may be considerably alleviated by a combination of epidural local anaesthetics, analgesia with reduced used of opioid drugs, minimally invasive surgery, and pharmacotherapy. ^{17 23} Preliminary studies show that such regimens, when combined with early enteral nutrition, may almost completely prevent paralytic ileus after colonic resection. ^{11 25}

The second to fifth postoperative day
Recovery from an operation depends on several factors, including the resolution of pain and fatigue. Fatigue in the early postoperative period is related to altered sleep within the hospital setting because of noise, environmental disturbances, drugs, and possibly inflammatory factors. ^{30 31} Loss of muscle strength and loss of weight because of reduced food intake have been related to fatigue, which occurs after a week or so.²⁴ Reduction of surgical stress, early enteral nutrition, and mobilisation are therefore important interventions which counteract fatigue and aid recovery.

	The future

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The initial promising results reported from fast track programmes raise the question of whether our traditional system of surgical care needs to be modified to improve surgical outcome. Shortened postoperative recovery may not necessarily require dependency on traditional surgical units, which rely on monitoring and high tech intervention, but rather we may need to emphasise postoperative "rehabilitation care units" which optimise pain relief, mobilisation, and nutrition.

Further developments in the specialty of fast track surgery will require more effective methods for reduction of perioperative stress, such as  blockade³² and improved combinations of analgesia and anaesthesia. In addition, more sophisticated approaches toward minimally invasive surgery and possibly pharmacological modification of the inflammatory response may be necessary. Integration of these approaches with aggressive rehabilitative techniques is also required.

In the future, the trend will be for shorter recovery periods after major operations. Importantly, the increased use of fast track surgery with shorter hospital stays will not necessarily lead to an increased burden on general practitioners as the patients will be discharged without the postoperative impairment of function usually observed and hopefully with less morbidity. Thus, with continued understanding of perioperative pathophysiology and improvements in perioperative care, it may not be unrealistic in the next few years for the insertion of a hip prosthesis, the excision of a large cancer, or the repair of an aortic aneurysm to be performed as day surgery.

	Footnotes

   Competing interests: None declared.

	References

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1.	Warner MA, Shields SE, Chute CG. Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA 1993; 270: 1337-1341.
2.	Mesei G, Chung F. Return hospital visits and hospital readmissions after ambulatory surgery. Ann Surg 1999; 230: 721-727[CrossRef][Medline].
3.	Mjåland O, Raeder J, Aasboe V, Trondsen E, Buanes T. Outpatient laparoscopic cholecystectomy. Br J Surg 1997; 84: 958-961[Medline].
4.	Bran DF, Spellman JR, Summitt Jr RL. Outpatient vaginal hysterectomy as a new trend in gynecology. AORN J 1995; 62: 810-814[Medline].
5.	Trondsen E, Mjaland O, Raeder J, Buanes T. Day-case laparoscopic fundoplication for gastro-oesophageal reflux disease. Br J Surg 2000; 87: 1708-1711[CrossRef][Medline].
6.	Podore PC, Throop EB. Infrarenal aortic surgery with a 3-day hospital stay: a report on success with a clinical pathway. J Vasc Surg 1999; 29: 787-792[CrossRef][Medline].
7.	Collier PE. Are one-day admissions for carotid endarterectomy feasible? Am J Surg 1995; 170: 140-143[CrossRef][Medline].
8.	Coveney E, Weltz CR, Greengrass R, Iglehart JD, Leight GS, Steele SM, et al. Use of paravertebral block anaesthesia in the surgical management of breast cancer: experience in 156 cases. Ann Surg 1998; 227: 496-501[CrossRef][Medline].
9.	Tovar EA, Roethe RA, Weissig MD, Lloyd RE, Patel GR. One-day admission for lung lobectomy: an incidental result of a clinical pathway. Ann Thorac Surg 1998; 65: 803-806[Abstract/Free Full Text].
10.	Kirsh EJ, Worwag EM, Sinner M, Chodak GW. Using outcome data and patient satisfaction surveys to develop policies regarding minimum length of hospitalization after radical prostatectomy. Urology 2000; 36: 101-107[CrossRef].
11.	Basse L, Hjort Jakobsen D, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000; 232: 51-57[CrossRef][Medline].
12.	Nierman E, Zakrzewski K. Recognition and management of preoperative risk. Rheum Dis Clin North Am 1999; 25: 585-622[Medline].
13.	Tonnesen H, Rosenberg J, Nielsen HJ, Rasmussen V, Hauge C, Pedersen IK, et al. Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: a randomised controlled trial. BMJ 1999; 318: 1311-1316[Abstract/Free Full Text].
14.	Egbert LD, Bant GE, Welch CE, Bartlett MK. Reduction of postoperative pain by encouragement and instruction of patients. N Engl J Med 1964; 207: 824-827.
15.	Daltroy LH, Morlino CI, Eaton HM, Poss R, Liang MH. Preoperative education for total hip and knee replacement patients. Arthritis Care Res 1998; 11: 469-478[CrossRef][Medline].
16.	White P. F. Ambulatory anesthesia advances into the new millennium. Anesth Analg 2000; 90: 1234-1235[Free Full Text].
17.	Kehlet H. Modification of responses to surgery by neural blockade: clinical implications. In: Cousins MJ, Bridenbaugh PO, eds. Neural blockade in clinical anesthesia and management of pain. Philadelphia: JB Lippincott, 1998:129-175.
18.	Rodgers A, Walker N, Schug S, McKee H, van Zundert A, Dage D, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anesthesia: results from an overview of randomised trials. BMJ 2000; 321: 1493-1497[Abstract/Free Full Text].
19.	Kehlet H. Surgical stress response: does endoscopic surgery confer an advantage? World J Surg 1999; 23: 801-807[CrossRef][Medline].
20.	Shea JA, Berlin JA, Bachwich DR, Staroscik RN, Malet PF, McGuckin M, et al. Indications for and outcomes of cholecystectomy: a comparison of the pre and postlaparoscopic eras. Ann Surg 1998; 227: 343-350[CrossRef][Medline].
21.	Sessler DI. Mild operative hypothermia. N Engl J Med 1997; 336: 1730-1737[Free Full Text].
22.	Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995; 221: 469[Medline].
23.	Kehlet H. Acute pain control and accelerated postoperative surgical recovery. Surg Clin North Am 1999; 79: 431-443[CrossRef][Medline].
24.	Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth 1997; 78: 606-617[Abstract/Free Full Text].
25.	Holte K, Kehlet H. Postoperative ileus: a preventable event. Br J Surg 2000; 87: 1480-1493[CrossRef][Medline].
26.	Power I, Barratt S. Analgesic agents for the postoperative period. Nonopioids. Surg Clin North Am 1999; 79: 275-297[Medline].
27.	McQuay H, Moore A, Justins D. Treating acute pain in hospital. BMJ 1997; 314: 1531-1535[Free Full Text].
28.	Watcha MF. The cost-effective management of postoperative nausea and vomiting. Anesthesiology 2000; 92: 931-933[CrossRef][Medline].
29.	Strunin L, Rowbotham D, Miles A, eds. The effective management of postoperative nausea and vomiting. London: Aesculapius Medical Press, 1999:1-42.
30.	Kehlet H, Rosenberg J. Surgical stress: pain, sleep and convalescence. In: Kinney JM, Tucker HN, eds. Physiology, stress and malnutrition: functional correlates, nutritional intervention. New York: Lippincott-Raven, 1997:95-112.
31.	Späth-Schwalbe E, Hansen K, Schmidt F, Schrezenmeier H, Marchall L, Burger K, et al. Acute effects of recombinant human interleukin-6 on endocrine and central nervous sleep functions in healthy men. J Clin Endocrinol Metab 1998; 83: 1573-1579[Abstract/Free Full Text].
32.	Poldermans D, Boersma E, Bax JJ, Thomson IR, van de Ven LL, Blankensteijn JD, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in high-risk patients undergoing vascular surgery. N Engl J Med 1999; 341: 1789-1794[Abstract/Free Full Text].

(Accepted 21 December 2000)