The document discusses the evolution and implementation of fast-track surgery, emphasizing a multimodal approach involving interdisciplinary care to improve recovery outcomes by reducing surgical stress and enhancing patient satisfaction. Key strategies include minimizing invasiveness, optimizing pain management, and facilitating early nutrition and mobilization, which collectively lead to decreased length of hospital stay and postoperative complications. However, there are calls for more extensive research to establish protocols and confirm the effectiveness of specific interventions in various surgical contexts.

1. Dhaval Mangukiya

2.  Length of hospital stay
 Morbidity
 Mortality
 Length of time to return to full function (work
or activities of daily living) and
 Patient satisfaction
(Ann Surg2008;248: 189 –198)

3.  Multimodal approach incorporates surgeons,
anesthesiologists, nurses, and physical
therapists as active participants of the care
team.
 Focuses on ERAS implementing evidence in
the fields of anesthesia, analgesia, reduction
of surgical stress, fluid management, minimal
invasive surgery, nutrition, and ambulation

4.  INITIAL DESCRIPTION OF SYSTEMIC
INJURY RESPONSES
 The stress response in surgical patients is
associated with tissue catabolism, organ
failure, and prolonged recovery
DouglasW.Wilmore From Cuthbertson to Fast-Track Surgery:
70Years of Progress in Reducing Stress in Surgical Patients;
Ann Surg. 2002 November; 236(5): 643–648.

5.  Reducing the body’s stress response after
surgery reduces the time needed to
recuperate.
 Achieved by
 Interventions around the operation
 Involving good information
 Better feeding before the operation
 Better pain treatment

6.  Fast track surgery combines various
techniques used in the care of patients
undergoing elective operations
 epidural or regional anesthesia
 minimally invasive techniques
 optimal pain control
 aggressive postoperative rehabilitation
[early enteral (oral) nutrition and ambulation]

7.  Management of patients in fast track surgery
BMJ Volume 322 February 24, 2001
 Evidence-Based Surgical Care and the Evolution of
Fast-Track Surgery Annals of Surgery Volume 248,
Number 2, August 2008
 Multimodal approach to postoperative recovery
Current Opinion in Critical Care 2009, 15:355–358
 H. Kehlet and K. Slim The future of fast-track surgery
British Journal of Surgery August 2012 Volume
99, Issue 8 Pages 1025–1168

10.  Education of patient
 Optimization ofAnaesthesia
 Reduction of Surgical stress
 Neural Blockade
 Minimal Invasive Surgical technique
 Pharmacological intervention
 Control of nausea, vomiting, ileus
 Adequate treatment of postoperative pain
 Appropriate use of tubes, drains & catheters
 Nursing care, nutrition and mobilization
 Discharge Planning

11.  Thromboprophylaxis reduces morbidity
 Perioperative use of oxygen therapy to decrease wound
and anastomotic complications requires further study
 Studies do not support the routine use of drains,
nasogastric tubes in a variety of abdominal operations
including gastric and hepatic surgery but necessary after
esophagectomy
 Routine use of bowel clearance procedures before colonic
surgery and prolonged use of urinary catheters are not
recommended
 The use of transverse abdominal incision may reduce pain
and pulmonary compromise and may be preferred to a
vertical incision provided sufficient exposure can be
achieved.

12.  Goal: “stress and pain free operation”

14.  Reduces sympathetic responses, undesirable
cardiac events, and wound morbidity

15.  “goal-directed fluid therapy”
 Requires individualized pre and postoperative
optimization of stroke volume determined by
providing small challenges of colloid and
assessing cardiac function by the esophageal
Doppler or other techniques
 Improvement in post-operative outcome
(reduced morbidity and hospital stay)

16.  Local anesthetic blocks
 Reduce the endocrine catabolic response
leading to attenuated protein loss
 In major abdominal procedures continuous
thoracic epidural analgesia with local
anesthetics has also been demonstrated to be
the most efficient technique to reduce
postoperative ileus
 Opioid sparing multimodal analgesia to facilitate
recovery

17.  decreasing the undesirable inflammatory
responses, pain, and catabolism
 Advantage in certain procedures
 No obvious clinical advantages after colonic
surgery, appendectomy, and hip
replacement

18.  Reducing insulin resistance and attenuating
catabolism
 Preliminary evidence
 Requires more large-scale randomized
studies in major procedures before final
recommendations

19.  Glucocorticoids: role in minor procedures to
reduce pain, nausea, and vomiting
 Anabolic agents in certain high-risk patients
 Insulin may serve as a future important
component for stress reduction
 Statins and beta blocker may be of advantage in
certain high-risk patients
 Early oral nutrition facilitated by antiemetics and
antiileus interventions (epidural analgesia, mild
laxatives, peripheral opioid-antago-nists) may
reduce catabolism

20.  Opioid sparing reduces nausea, vomiting, and
sedation
 Several agents demonstrate effectiveness
(nonsteroidal anti-inflammatory drugs, COX-
2 inhibitors, ketamine, gabapentin, local
anesthetic techniques).

21.  “*” -- evidence available, ready for
implementation
 “+” -- less evidence available, need for
further study

24.  Multimodal approach to postoperative
recovery Current Opinion in Critical Care
2009, 15:355–358

25.  Fast-track colonic surgery is well tolerated and
feasible and with supportive data of reduced
postoperative morbidity in addition to reduction
of hospital stay
 Recent data have also shown enhanced recovery
after ileostomy closure with fast-track programs
 Schwenk W et al. ‘Fast-track’ rehabilitation for elective colonic surgery in
Germany-prospective observational data from a multicentre quality
assurance programme. Int J Colorectal Dis 2008; 23:93–99.
 JohYG et al.Standardized postoperative path-way: accelerating recovery
after ileostomy closure. Dis Colon Rectum 2008; 51:1786– 1789

26.  Evidence-based care programs to improve
outcome have been further supported by
fast-track clinical pathways
 Low DE. Evolution in perioperative management of patients undergoing oesophagectomy.
Br J Surg 2007; 94:655 –656.
 Jiang K, Cheng L, Wang JJ,et al.Fast track clinical pathway implications in
esophagogastrectomy. World J Gastroenterol 2009; 15:496 –501

27.  Pancreaticoduodenectomy with significant reductions
in length of stay as well as a potential to reduce
morbidity
 Further studies in which surgical technique, use of
drains, tubes, stents, fluid management, early oral
nutrition and so on are reconsidered and adjusted to
recent evidence
 Berberat PO, Ingold H, Gulbinas A,et al.Fast track: different implications in
pancreatic surgery. J Gastrointest Surg 2007; 11:880 –887.
 Balzano G, Zerbi A, Braga M,et al.Fast-track recovery programme after
pancreatico-duodenectomy reduces delayed gastric emptying. Br J Surg 2008;
95:1387 –1393

28.  Limited published in liver resection with
positive results stimulating for future
research and documentation of the concept.
 van Dam RM, Hendry PO, Coolsen MM, et al. Initial experience with a multimodal enhanced
recovery programme in patients undergoing liver re-section. Br J Surg 2008; 95:969 –975.

29. Fast track surgery versus conventional
recovery strategies for colorectal surgery
Willem R Spanjersberg et al
2011, Issue 2
(Art. No.:CD007635. DOI: 10.1002/14651858.CD007635.pub2)

30.  Mortality (both early and late), with early
mortality defined as death within 30 days
 Overall complications
 Major (including abdominal sepsis, anastomotic
leakage, need for reoperation, persistent ileus,
intra-abdominal abscesses, bleeding, burst
abdomen, late incisional hernia and adhesions)
 Minor (pneumonia, wound infection, deep vein
thrombosis, and urinary tract infection)
 length of hospital stay

31.  Operative time
 Economical evaluation
 Quality of life

33.  According to ERAS principles includes 17
separate interventions (Lassen 2009).
 The actual number of interventions used
differed greatly between included trials
 Trials that were considered high quality used
11 or 12 of the 17 ERAS prespecified
interventions versus 0 or 1 in the conventional
group (pertaining epidural analgesia)

34.  Forest plot of comparison
 ERAS patients developed significantly less
complications overall (RR 0.52; 95% CI 0.38 to
0.71, p<0.0001)
 When divided into major and minor
complications, however, no significant
difference
 The risk of readmissions was not increased
with ERAS patients,

35.  Length of hospital stay was significantly
reduced in the ERAS group
 The use of analgesics and especially the use
of epidural analgesia was studied in two
trials, with contradictory results.

36.  Implementation of the ERAS protocol are not available in
literature
 Long term outcome parameters like oncological survival,
quality of life after surgery are not investigated yet
 Economical effects of the intervention have not been
investigated prospectively
 Evidence on the effects of ERAS with different operative
techniques like laparoscopy have not been analysed
 The effect of separate interventions in the ERAS protocol
have not been independently studied
 Exact knowledge on separate effects could also aid in
making ERAS programs more (cost-) efficient and
effective.

37.  The quantity and especially quality of data are low.
Analysis shows a reduction in overall complications,
but major complications were not reduced. Length of
stay was reduced significantly.
 ERAS seems safe, but the quality of trials and lack of
sufficient other outcome parameters do not justify
implementation of ERAS as the standard of care.
 Within ERAS protocols included, no answer regarding
the role for minimally invasive surgery (i.e.
laparoscopy) was found
 Protocol compliance within ERAS programs has not
been investigated
 More specific and large RCT’s are needed