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Acs0110 Fast Track Surgery

  1. 1. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 10 Fast Track Surgery — 1 10 FAST TRACK SURGERY Henrik Kehlet, M.D., Ph.D., F.A.C.S. (Hon.), and Douglas W.Wilmore, M.D., F.A.C.S. Over the past several decades, surgery has undergone revolution- surgery must be based on a process of multidisciplinary collabo- ary changes that are leading to improved treatments (involving ration that embraces not only the surgeon, the anesthesiologist, lower risk and better outcome) for an increasing number of dis- the physiotherapist, and the surgical nurse but also the patient. eases. These salutary developments are the result of more ad- More specifically, fast track surgery depends on the inclusion and vanced anesthetic techniques, new methods of reducing the peri- integration of a number of key constituent elements (see below). operative stress response, wider application of minimally invasive techniques, improved understanding of perioperative pathophysi- ology, and more sophisticated approaches to the prevention of Constituent Elements postoperative organ dysfunction. Currently, many operations that EDUCATION OF THE PATIENT once necessitated hospitalization can readily be performed in the outpatient setting; in addition, many major procedures are now To obtain the full advantages of a fast track surgical program, associated with a significantly reduced duration of hospitalization it is essential to provide patients with information about their peri- and a shorter convalescence. operative care in advance of the procedure. Such educational Although these anesthetic and surgical developments are the efforts often serve to reduce patients’ level of anxiety and need for result of basic scientific and clinical research, they have also been pain relief, thereby providing a rational basis for collaboration influenced by governmental and managed care policies aimed at with health care personnel, a process that is crucial for enhancing encouraging more cost-effective treatments. Such extraclinical postoperative rehabilitation.1-3 Patients can supplement the infor- influences, coupled with new clinical developments, have resulted mation they receive directly from health care providers by access- in novel approaches designed to enhance the cost-effectiveness of ing reference sources such as health care, such as so-called fast track surgery, critical pathways, aboutbroch.html, a collection of electronic brochures on specific and various types of clinical guidelines. To understand the true clinical procedures that is provided by the American College of potential value of such approaches, it is essential to recognize that Surgeons. their aim is not merely to ensure that fewer health care dollars are OPTIMIZATION OF ANESTHESIA spent but, more important, to ensure that better and more effi- cient health care is delivered. Although these novel approaches The introduction of rapid-onset, short-acting volatile anesthet- may reduce cost, their primary purpose is to improve surgical ics (e.g., desflurane and sevoflurane), opioids (e.g., remifentanil), management by reducing complications and providing better out- and muscle relaxants has enabled earlier recovery from anesthesia comes. In what follows, we outline the basic concept, primary and thereby facilitated ambulatory and fast track surgery.4 Al- components, and current results of fast track surgery, which is a though use of these newer general anesthetic agents has resulted comprehensive approach to the elective surgical patient that is in quicker recovery of vital organ function after minor surgical designed to accelerate recovery, reduce morbidity, and shorten procedures, it has not been shown to decrease stress responses or convalescence. mitigate organ dysfunction after major procedures. Regional anesthetic techniques (e.g., peripheral nerve blocks and spinal or epidural analgesia), on the other hand, have several Basic Concept advantages in addition to providing anesthesia. Such advantages Fast track surgery involves a coordinated effort to combine (1) include improved pulmonary function, decreased cardiovascular preoperative patient education; (2) newer anesthetic, analgesic, demands, reduced ileus, and more effective pain relief. Neural and surgical techniques whose aim is to reduce surgical stress blockade is the most effective technique for providing postopera- responses, pain, and discomfort; and (3) aggressive postoperative tive pain relief, and it has been shown to reduce endocrine and rehabilitation, including early enteral nutrition and ambulation. It metabolic responses to surgery [see 1:6 Postoperative Pain]. For a also includes an up-to-date approach to general principles of pronounced reduction in perioperative stress after a major opera- postoperative care (e.g., use of tubes, drains, and catheters; mon- tion, continuous epidural analgesia for 24 to 72 hours is neces- itoring; and general rehabilitation) that takes into account the sary.5,6 A meta-analysis of randomized trials evaluating regional revisions to traditional practice mandated by current scientific anesthesia (primarily involving patients undergoing operations on findings. It is believed that by these means, fast track surgery can the lower body) found that morbidity was 30% lower with region- shorten the time required for full recovery, reduce the need for al anesthesia than with general anesthesia.7 However, the effect of hospitalization and convalescence, and lower the incidence of continuous epidural analgesia on outcome after major abdominal generalized morbidity related to pulmonary, cardiac, thromboem- or thoracic procedures has been questioned in the past several bolic, and infectious complications.1-3 years. In three large randomized trials,8-10 no beneficial effect on For an accelerated recovery program of this type to succeed, overall morbidity could be demonstrated, except for a slight proper organization is essential. In general terms, fast track improvement in pulmonary outcome, and the duration of hospi-
  2. 2. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 10 Fast Track Surgery — 2 talization was not reduced. It should be remembered, however, tions for hip fracture received either low-dose GH (20 mg/kg/day) that in these studies, either an epidural opioid regimen or a pre- or placebo.28 Overall, those in the GH group were able to return dominantly epidural opioid regimen was employed and that the to their prefracture living situation earlier than those in the place- perioperative care regimens either were not described or were not bo group. A 1999 study reported increased mortality when GH revised according to current scientific data regarding the use of was administered to ICU patients,29 but a 2001 meta-analysis nasogastric tubes, early oral feeding, mobilization, and other care failed to confirm this observation.30 More work is necessary parameters.3 We believe, therefore, that for further assessment of before definitive conclusions can be formed in this regard. the role of continuous epidural local analgesic regimens that Postoperative insulin resistance is an important metabolic fac- include local anesthetics in improving outcome, an integrated tor for catabolism. There is evidence to suggest that preoperative approach within the context of fast track surgery is required.6 oral or intravenous carbohydrate feeding may reduce postopera- Perioperative measures should also be taken to preserve intra- tive insulin resistance.31 Whether this approach yields clinical operative normothermia. Hypothermia may lead to an augment- benefits in terms of improved recovery remains to be deter- ed stress response during rewarming, impaired coagulation and mined,31,32 but its simplicity, its clear pathophysiologic rationale, leukocyte function, and increased cardiovascular demands. and its low cost make it a potentially attractive option. Preservation of intraoperative and early postoperative normother- CONTROL OF NAUSEA, VOMITING, AND ILEUS mia has been shown to decrease surgical site infection, intraoper- ative blood loss, postoperative cardiac morbidity, and overall The ability to resume a normal diet after a surgical procedure catabolism.11 (whether minor or major) is essential to the success of fast track surgery. To this end, postoperative nausea, vomiting, and ileus REDUCTION OF SURGICAL STRESS must be controlled. Principles for rational prophylaxis of nausea The neuroendocrine and inflammatory stress responses to and vomiting have been developed on the basis of systematic surgery increase demands on various organs, and this increased reviews33: for example, 5-HT3 receptor antagonists, droperidol, demand is thought to contribute to the development of postop- and dexamethasone have been shown to be effective in this erative organ system complications. At present, the most impor- regard, whereas metoclopramide is ineffective.There is some rea- tant of the techniques used to reduce the surgical stress response son to think that multimodal antiemetic combinations may be are regional anesthesia, minimally invasive surgery, and pharma- superior to single antiemetic agents; unfortunately, the data cur- cologic intervention (e.g., with steroids, beta blockers, or anabol- rently available on combination regimens are relatively sparse. In ic agents).12 addition, analgesic regimens in which opioids are cut back or Neural blockade with local anesthetics reduces endocrine and eliminated have been shown to decrease postoperative nausea metabolic (specifically, catabolic) activation and sympathetic stim- and vomiting. ulation, thereby decreasing the demands placed on organs and Paralytic ileus remains a significant cause of delayed recovery reducing loss of muscle tissue; however, regional anesthetic tech- from surgery and contributes substantially to postoperative dis- niques have no relevant effect on inflammatory responses.5,6 comfort and pain. Of the various techniques available for manag- Minimally invasive surgical techniques clearly decrease pain ing ileus,34,35 continuous epidural analgesia with local anesthetics and lessen inflammatory responses,13-15 but they appear to have is the most effective, besides providing excellent pain relief. Now relatively little, if any, effect on endocrine and metabolic responses. that cisapride has been taken off the market, no effective anti- Pharmacologic intervention with a single dose of a glucocorti- ileus drugs are available. In a 2001 study, however, a peripheral- coid (usually dexamethasone, 8 mg) given before a minor proce- ly acting mu opioid receptor antagonist significantly reduced dure has led to reduced nausea, vomiting, and pain, as well as to nausea, vomiting, and ileus after abdominal procedures, without decreased inflammatory responses (interleukin-6), with no ob- reducing analgesia.36 If further studies confirm these findings, use served side effects.16,17 This intervention may facilitate recovery of peripherally acting opioid antagonists may become a popular from minor (i.e., ambulatory) procedures18; however, the data and effective way of improving postoperative recovery; this treat- from major procedures are inconclusive.The use of perioperative ment is simple and apparently has no major side effects. beta blockade to reduce sympathetic stimulation and thereby ADEQUATE TREATMENT OF POSTOPERATIVE PAIN attenuate cardiovascular demands has been shown to reduce car- diac morbidity,19 as well as to reduce catabolism in burn patients Despite ongoing development and documentation of effective [see Elements of Contemporary Practice:6 Risk Stratification, Pre- postoperative analgesic regimens—such as continuous epidural operative Testing, and Operative Planning].20,21 Perioperative beta analgesia in major operations, patient-controlled analgesia blockade may therefore become an important component of efforts (PCA), and multimodal (balanced) analgesia that includes non- to facilitate recovery in fast track surgical programs. steroidal anti-inflammatory drugs as well as stronger agents37-39 For patients whose nutritional status is normal, oral feeding ad [see 1:6 Postoperative Pain]—postoperative pain still is too often libitum is appropriate in the postoperative period. For patients inadequately treated. Improved pain relief, facilitated by an acute who are elderly or nutritionally depleted, nutritional supplementa- pain service,40 is a central component of any fast track surgery tion, administration of an anabolic agent (e.g., oxandrolone or an- program and is a prerequisite for optimal mobilization and oral other anabolic steroid,22-24 insulin,25 or growth hormone [GH]26,27) nutrition, as well as a valuable aid in reducing surgical stress to enhance deposition of lean tissue, or both may be beneficial. responses.37 Most of the studies addressing the use of anabolic agents have APPROPRIATE USE OF TUBES, DRAINS, AND CATHETERS focused on critically ill catabolic patients, in whom both indirect effects (e.g., improved nitrogen balance26) and direct effects (e.g., There is substantial support in the literature for the idea that improved wound healing and decreased length of stay with GH in nasogastric tubes should not be used routinely in patients undergo- burned children27 and decreased mortality with insulin in critical- ing elective abdominal surgery.1,2 Randomized trials indicated that ly ill patients25) on outcome have been demonstrated. In a study drains offered little benefit after cholecystectomy, joint replace- published in 2000, a group of elderly patients undergoing opera- ments, colon resection, thyroidectomy, radical hysterectomy, or
  3. 3. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 10 Fast Track Surgery — 3 pancreatic resection1,3,41 but that they might limit seroma forma- or a slightly modified fast track care program. On the whole, the tion after mastectomy.1,3 Such postmastectomy drainage does not preliminary results from these studies are very positive: fast track necessarily impede hospital discharge, and the patient generally surgery is associated with shorter hospital stays, reduced or at may be treated on an outpatient basis. Urinary catheterization has least comparable morbidities, and low readmission rates, with no been routinely performed after many operations, but scientific doc- apparent decrease in safety. umentation of the requirement for this measure is often lacking. In Studies of fast track surgery in which organ function was general, catheterization beyond 24 hours is not recommended with assessed postoperatively and compared with organ function after colorectal procedures, except with the lowest rectal procedures, for traditional care found fast track surgery to be associated with ear- which 3 to 4 days of catheterization may be indicated.3 lier ambulation,43,44 superior postoperative muscle function,44 Although tubes, drains, and catheters may lead to morbidity improved oral nutritional intake,45 better preservation of lean body only when used for extended periods, they do tend to hinder mass,43,45 reduced postoperative impairment of pulmonary func- mobilization, and they can raise a psychological barrier to the pa- tion,43 earlier recovery of GI motility,46 and mitigation of the de- tient’s active participation in postoperative rehabilitation. There- crease in exercise capacity and impairment of cardiovascular fore, such devices should be used not routinely but selectively, in response to exercise that are usually expected after an operation.43 accordance with the available scientific documentation. The few randomized trials performed to date (mostly involving patients undergoing cholecystectomy, colonic resection, or mastec- NURSING CARE, NUTRITION, AND MOBILIZATION tomy) reported that fast track programs increased or at least main- Postoperative nursing care should include psychological sup- tained patient satisfaction while achieving major cost reductions. port for early rehabilitation, with a particular focus on encourag- ing the patient to resume a normal diet and become ambulatory as soon as possible. Early resumption of an oral diet is essential for Future Developments self-care; furthermore, according to a 2001 meta-analysis of con- The initial promising results from the fast track surgical pro- trolled trials, it may reduce infectious complications and shorten grams studied suggest that such programs can achieve major care hospital stay after abdominal procedures, without increasing the improvements in terms of reducing postoperative stay. At present, risk of anastomotic dehiscence.42 In addition, early resumption of however, sufficient scientific documentation is lacking for many enteral feeding may reduce catabolism and may be facilitated by commonly performed major operations. Thus, there is a need for the methods used to reduce postoperative nausea, vomiting, and additional data—in particular, data on the potential positive ileus (see above). effects of fast track surgery on postoperative morbidity. The nec- Postoperative bed rest is undesirable because it increases mus- essary data would probably be best obtained through multicenter cle loss, decreases strength, impairs pulmonary function and tis- trials using identical protocols. Randomized trials within the same sue oxygenation, and predisposes to venous stasis and throm- unit that allocate some patients to suboptimal care recommenda- boembolism.3 Accordingly, every effort should be made to enforce tions for pain relief, mobilization, and nutrition would be difficult postoperative mobilization; adequate pain relief is a key adjuvant to perform, if not unethical, though a few such reports have been measure in this regard. published on colon surgery patients.44,47 Organization is essential for good postoperative nursing care: a As yet, it has not been conclusively demonstrated that reducing prescheduled care map should be drawn up, with goals for reha- the duration of hospitalization necessarily reduces morbidity,48 bilitation listed for each day. though data from studies addressing colonic and vascular proce- dures suggest that nonsurgical (i.e., cardiopulmonary and throm- DISCHARGE PLANNING boembolic) morbidity may be reduced and overall postoperative Given that a primary result of fast track surgery is reduced recovery (assessed in terms of exercise performance and muscle length of hospitalization, discharge planning must be a major con- power) enhanced. More study is required in this area. Future tri- sideration in the preoperative patient information program, as als should also focus on identifying any factors that might be lim- well as during hospitalization. Careful, detailed discharge plan- iting even more aggressive early recovery efforts, so that more ning is essential for reducing readmissions and increasing patient effective fast track programs can be designed. Finally, studies are safety and satisfaction. The discharge plan should include (1) needed to identify potential high-risk patient groups for whom fast detailed information on the expected time course of recovery, (2) track surgery may not be appropriate or who may need to be hos- recommendations for convalescence, and (3) encouragement of pitalized for slightly longer periods to optimize organ function.47 enteral intake and mobilization. For patients with a significant There has been considerable interest in whether the use of crit- degree of postoperative disability, various acute care facilities are ical pathways improves postoperative care. Preliminary studies available after hospital discharge. It should be kept in mind, how- involving coronary artery bypass grafting, total knee replacement, ever, that the integrated care approach fundamental to fast track colectomy, thoracic procedures, and hysterectomy suggested that surgery is specifically intended as a way of limiting or preventing critical pathways may reduce length of hospital stay, but the such disability, thereby reducing patients’ need for and depen- reduction is no greater than can be observed in neighboring hos- dence on postdischarge care facilities. pitals that do not use critical pathways.49 Thus, the initial enthusi- asm for critical pathways notwithstanding, conclusive evidence that they have a beneficial effect on postoperative care is still lack- Reported Results ing.The continuously decreasing length of stay noted in hospitals Ongoing efforts to formulate multimodal strategies aimed at without fast track programs may be partly attributable to the improving postoperative outcome have led to the development of intense competition within the health care system, which can lead a variety of fast track surgical programs [see Table 1]. Most of the to changes in care principles even without the formal adoption of studies published to date have been descriptive ones reporting critical pathways or similar systems.49 consecutive patient series from single centers, the findings from All of the studies on the economic implications of fast track sur- which have often been confirmed by other groups using the same gical programs and critical pathways have documented substantial
  4. 4. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 10 Fast Track Surgery — 4 Table 1 Results from Selected Fast Track Surgical Programs Type of Operation Postoperative Hospital Stay Comments and Other Findings Abdominal procedures Inguinal hernia repair59-61 1.5–6 hr Large consecutive series using local infiltration anesthesia in > 95%, with one series59 using unmonitored anesthesia; documented low morbidity, with no urinary retention; patient satisfaction ~90%, cost reduction > $250 with local anesthesia Cholecystectomy (laparoscopic,62-67 > 80% discharge on same day Large consecutive series, with documented safety and patient satisfaction > 80%; mini-incision68) cost reduction of $750/patient in randomized study64; recovery of organ functions within 2–3 days, with <1 wk convalescence67; similar results with mini-incision in consecutive series68 Fundoplication69,70 > 90% < 23 hr Large consecutive series with documented safety70 Open43,44,46,47,56,71-76 and laparo- 2–4 days Consecutive series including high-risk patients; reduced cardiopulmonary morbidity, scopic72,77-79 colorectal procedures readmission rates 0%–15%; no documented advantages of laparoscopy-assisted colonic resection, though costs may be reduced72; ileus reduced to < 48 hr in > 90% of patients,46,56 with improved muscle and pulmonary function in fast track patients and better preservation of postoperative body composition43; one random- ized study showed similar morbidity, readmissions, and satisfaction with fast track versus traditional care47 Complex pelvic-colorectal 3–6 days Short stay80 (~4–6 days) even with additional stoma; low readmission rate (7%) procedures80,81 Rectal prolapse82 80% < 24 hr Consecutive series (N = 63) with Altemeier repair; 5% readmission rate (nonserious indications) Pancreaticoduodenectomy,83,84 — Hospital stay decreased by implementation of clinical pathway complex biliary tract procedures85 Mastectomy86-90 90% < 1 day Large cumulative series; documented safety and major cost reduction with high patient satisfaction; no increased morbidity with fast track, but less wound pain and improved arm movement and no increase in risk of psychosocial complications Vascular procedures Carotid endarterectomy91-94 90% < 1 day Surgery done with local anesthesia; specialized nurses and wards Lower-extremity arterial bypass95 2–3 days Large series (N = 130); documented safety Abdominal aortic aneurysmectomy96,97 ~3 days Preliminary studies (N = 5096 and N = 7797); documented early recovery and safety; one study with epidural analgesia,97 one without96 Urologic procedures Radical prostatectomy98 ~75% 1 day Large consecutive series (N = 252); documented safety and patient satisfaction Laparoscopic adrenalectomy99-101 < 1 day Small series; safety and low morbidity suggested Cystectomy102,103 7 days Improved mobilization, bowel function, and sleep recovery with fast track surgery102; low mortality; ileus a problem102,103 Laparoscopic donor nephrectomy104 < 1 day Preliminary study (N = 41); low readmission rate (2%) Open donor nephrectomy105 2 days — Pulmonary procedures106-110 ~1 day in some series,106,107 Shortest stay with fast track protocol including revision of drainage principles106,107; ~4–5 days in others safety with very early discharge suggested Other procedures Craniotomy111 ~40% < 24 hr Large consecutive series (N = 241) including tumor surgery; local anesthesia used; low readmission rate; safety suggested Parathyroid procedures112 ~90% ambulatory Selected consecutive series (N = 100); regional anesthesia and intraoperative adenoma localization employed; documented safety Vaginal procedures113 ~1 day Consecutive series (N = 108); surgery done with local anesthesia cost savings. It should, however, be borne in mind that the last thereby achieving additional cost savings. As noted, the large-scale portion of a hospital stay is much less expensive than the initial data with detailed patient description and stratification that are portion; thus, the cost savings in this area may turn out to be needed to clarify the improvements achieved by fast track surgery smaller than they would at first appear.50-52 This cavil should not are, unfortunately, lacking at present, but so far, all indications are hinder further development and documentation of fast track that postoperative morbidity is comparable or reduced. surgery, because inherent in the concept is the idea that revision A commonly expressed concern is that fast track surgery might and optimization of perioperative care may also reduce morbidity, increase the burden on general practitioners and other parts of the
  5. 5. © 2004 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice ELEMENTS OF CONTEMPORARY PRACTICE 10 Fast Track Surgery — 5 nonhospital care system. The evidence currently available clearly addressed patient functional status after fast track colonic surgery indicates that increased use of ambulatory surgery is safe and is suggested that muscle function, exercise capacity, and body compo- associated with a very low readmission rate.53,54 After major proce- sition are better preserved with this approach than with traditional dures such as colorectal surgery, however, readmissions are often care, in which surgical stress, insufficient nutrition, and prolonged unpredictable, and the readmission rate is not significantly reduced immobilization typically lead to significant deterioration of organ by keeping patients in the hospital for an additional 2 to 3 days.55,56 function. Accordingly, an optimal fast track surgery regimen should Moreover, in some studies of patients who have undergone coro- aim at early recovery of organ function, not just early discharge. nary bypass57 and hip replacement,58 earlier discharge and hospital In summary, the basic concept of fast track surgery, which cost savings have been offset by increased use of postacute rehabil- could be expressed as multimodal control of perioperative patho- itation services. Thus, any assessment of the costs associated with physiology, seems to be a highly promising approach to improving fast track surgery should include the total period during which care surgical outcome. We believe that the principles and techniques (including both hospital care and rehabilitation care) is delivered. embodied in this approach will eventually be integrated into the Again, however, it should be emphasized that the basic concept care of all surgical patients. To this end, resources should be allo- of fast track surgery implies control of perioperative pathophysiolo- cated for evaluation and documentation of the effects of fast track gy with the aim of enhancing recovery and thereby reducing the surgery and related systems on cost, postoperative morbidity, safe- need for postdischarge care.The relatively few published studies that ty, and overall patient well-being. References 1. Kehlet H: Multimodal approach to control postop- 17. Holte K, Kehlet H: Perioperative single dose gluco- tance and elective surgery. Surgery 128:757, 2001 erative pathophysiology and rehabilitation. Br J corticoid administration: pathophysiological effects 32. Henriksen MG, Hessov I, Vind Hansen H, et al: Anaesth 78:606, 1997 and clinical implications. J Am Coll Surg 195:694, Effects of preoperative oral carbohydrates and pep- 2002 tides on postoperative endocrine response, mobi- 2. Wilmore DW, Kehlet H: Management of patients in fast track surgery. BMJ 322:473, 2001 18. Bisgaard T, Klarskov B, Kehlet H, et al: Preopera- lization, nutrition and muscle function in abdomi- tive dexamethasone improves surgical outcome nal surgery. Acta Anaesthesiol Scand 47:191, 2003 3. Kehlet H, Wilmore DW: Multi-modal strategies after laparoscopic cholecystectomy: a randomized to improve surgical outcome. Am J Surg 183:630, 33. Gan TJ, Meyer T, Apfel CC, et al: Consensus guide- double-blind placebo-controlled trial. Ann Surg 2002 lines for managing postoperative nausea and vomit- 238:651, 2003 ing. Anesth Analg 97:62, 2003 4. White PF: Ambulatory anesthesia—advances into 19. Schmidt M, Lindenauer PK, Fitzgerald JL, et al: the new millennium. Anesth Analg 98:1234, 2000 34. Holte K, Kehlet H: Postoperative ileus: a prevent- Forecasting the impact of a clinical practice guide- able event. Br J Surg 87:1480, 2000 5. 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