Recent advances: Management of patients in fast track surgery

Abstract

What is fast track surgery? 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. Recent advances Newer techniques in surgery and anaesthesia that reduce the postoperative stress response are improving surgical outcome Use of these methods in day surgical units will be extended to more complex surgical procedures, thus decreasing length of time in hospital Regional anaesthesia and minimally invasive operative techniques are central to these changes Shortened postoperative recovery should be the focus of rehabilitation care units, which optimise pain relief, mobilisation, and nutrition Early patient discharge will be accompanied by functional recovery and presumably less morbidity View larger version: In this window In a new window Fig 1 Factors contributing to postoperative morbidity View larger version: In this window In a new window Fig 2 Interventions needed for major improvement in surgical outcome View this table: In this window In a new window Recent developments on fast track surgery from single centre studies Examples of fast track surgery Ambulatory or 24 hour surgery Extensive knee and shoulder reconstruction (laparoscopy/endoscopy) Vaginal hysterectomy Gastric fundoplication (laparoscopy/endoscopy) Splenectomy (laparoscopy/endoscopy) Adrenalectomy (laparoscopy/endoscopy) Donor nephrectomy (laparoscopy/endoscopy) Mastectomy Cholecystectomy (laparoscopy/endoscopy) Short stay surgery—1 to 4 days Colectomy Total hip and knee replacement Aortic aneurysmectomy Pneumonectomy and lobectomy Radical prostatectomy Peripheral vascular reconstruction 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