Objectives: On completion of this article, the reader should be able to recognize that fast-track
protocols are safe and cost-effective, while improving overall patient outcomes by
reducing the surgical stress response; summarize the components of fast-track surgery
by each perioperative phase; understand the role of minimally invasive surgery in
colon and rectal resections and perioperative adjuncts; and outline future directions
for fast-track surgery.
In 2010, health-care expenditures in the United States neared $2.6 trillion, 10 times
the amount spent in 1980.[1] Current projections show national health expenditures continuing to increase and
account for 20% of the gross domestic product by 2020.[2] The reduction in health-care expenditures and more efficient use of medical resources
is now an overriding health policy priority with the two-pronged goal of improving
patient outcomes while decreasing overall cost. This is especially relevant in the
field of colorectal surgery because of a disproportionately higher complication rate
and longer length of stay when compared with other operative procedures. Current reports
show colorectal surgery accounting for 25% of all operative complications and an average
length of stay of 8 to 12 days for a standard elective colon resection.[3]
[4]
[5]
[6]
During the last several decades, there has been growing recognition that surgical
stress caused by major surgery results in derangements in organ function and subsequently
increases postoperative morbidity. To combat this, Kehlet introduced a concept of
enhanced recovery after surgery (ERAS) or fast-track pathways, with the goal of using
current evidence and multimodal therapies to reduce surgical stress and enhance postoperative
recovery. This was achieved by asking the simple question: Why is the patient in the
hospital today?[7] The pathway elements are perioperative care interventions that focus on anesthesia,
analgesia, reduction of surgical stress (both endocrine-metabolic and inflammatory
responses), goal-directed fluid therapy, the prevention of nausea and ileus (return
of bowel function), thromboembolic prophylaxis, minimally invasive techniques, nutrition,
and early mobilization.[8]
The benefits and safety of fast-track protocols (FTPs) are validated in multiple randomized
controlled trials.[9] Patients in these studies had faster return of bowel function, shorter length of
hospitalization, and decreased complication rates. These findings were confirmed by
several meta-analyses and a recent Cochrane Review.[10]
[11]
[12]
[13] The most recent meta-analysis included 7 randomized control trials with 852 patients.
Lv et al found patients randomized to FTP care had a significantly decreased length
of stay (mean difference: –1.88; 95% confidence interval [CI], –2.91 to 0.86, p = 0.0003) and overall rate of complications (relative risk [RR] = 0.69; 95% CI, 0.51–0.93),
p = 0.01) without differences in mortality (RR = 1.02; 95% CI = 0.40–2.57, p = 0.97).[13] Initial reports demonstrated higher readmission rates in two small studies (likely
secondary to the earlier discharge); however, in several subsequent meta-analyses,
there was no significant difference in readmission rates between conventional care
and FTP patients.[10]
[11]
[12]
[13]
[14]
[15]
Regarding concerns of higher cost, multiple studies have found FTPs to be cost-efficient,
even including those that use laparoscopic surgery. Laparoscopic surgery is more expensive
than open surgery secondary to disposable instruments, additional operative time,
and mastery of the learning curve.[16]
[17]
[18] However, overall costs for laparoscopy are offset by reduction in length of stay,
inpatient resources, and decreased complications. Delaney and colleagues reported
implementation of an FTP for minimally invasive surgery at a single institution that
required no additional personnel or expense.[19] A cost analysis in New Zealand found an initial implementation cost of $102,000
was offset by a reduction in postoperative resource utilization and an overall cost
savings of $6,900 per patient.[20]
This review focuses on the evidence regarding fast-track pathways, use of minimally
invasive surgery and its role in fast-track pathways, newer perioperative interventions,
and future directions. Some brief overviews of the individual components are reviewed
here with more detailed evidence regarding each component found elsewhere within this
volume.
Implementing an ERAS Pathway
Fast-track surgery is a multimodal effort to improve patient outcomes and decrease
cost of care. As such, implementation of fast-track surgery pathway requires a multimodal
approach involving the entire patient-care team. A fast-track surgery team includes
a team leader, anesthetists, nurses, and ancillary staff such as physical therapists,
enterostomal therapists, and social workers—all trained in fast-track surgery principles.[21]
Despite substantial evidence in the literature on the benefit and cost savings of
fast-track surgery, implementation of a FTP is challenging. Several series have shown
that the transition from concept to wide clinical practice is delayed.[19]
[22]
[23]
[24]
[25] In 2010, a Web-based survey of 407 general and colorectal surgeons found that only
30% of the surgeons practiced in hospitals that had implemented an FTP.[26] Internal barriers include lack of awareness of current evidence-based literature
regarding benefits of fast-track surgery, disagreement with current findings, or belief
that a particular hospital or institution cannot support fast-track surgery protocols.
External barriers include a lack of support from staff (hospital administration, nurses,
and physicians), inability to collect and maintain outcome data, lack of expertise
in FTPs, financial concerns regarding cost of implementation and maintenance of FTP,
and insufficient number of support staff.[8]
[27] The key to overcome many of these barriers is having the senior clinical and administrative
leadership buy-in to fast-track surgery and the protocols required to make it successful.[19] In addition, acceptance by the patient and his or her support system is mandatory.
Education and communication of each component of fast-track pathway begins at the
preoperative visit and is performed in verbal and written communications in simple,
plain language. As the patient enters different phases of fast-track pathway, goals
such as early ambulation, oral intake, pain control, and other discharge criteria
are reiterated by all members of the team. A successful FTP hinges on patient and
provider compliance, with the postoperative phase being the most critical in decreasing
length of stay.[28]
Components of Fast-Track Protocol
The Preoperative Phase
FTP interventions begin with proper patient selection involving a thorough history
and physical examination with all organ systems carefully reviewed to determine whether
a patient requires preoperative optimization. Patients with chronic obstructive pulmonary
disease, coronary artery disease, and diabetes mellitus may require additional workup
and treatment before proceeding with surgery.[29] Ideal patients for the FTP are healthy individuals who have an American Society
of Anesthesiologist (ASA) score of 1 or 2, whereas typically only a select group of
patients with ASA score of 3 are optimal candidates.[30] Commonly reported contraindications for FTP include malnourishment (greater than
10% weight loss), immobility or minimally immobile, active alcohol abuse (more than
5 drinks per day) or dependence, poorly controlled psychiatric disorders or lack of
social support, and inability to follow-up for postoperative visits or complications.[29]
[30] Patients with active alcohol abuse or dependence should be abstinent at least 4
weeks prior to surgery to decrease postoperative morbidity.[31]
[32] Active tobacco abusers are strongly encouraged to quit at least 4 weeks prior to
surgery to prevent respiratory complications, although an optimal cessation period
to decrease immune response and improve wound healing has yet to be determined.[33]
[34]
[35] The type of procedure being performed should also be a factor in whether FTP is
utilized. Emergent procedures for ischemia, obstruction, or perforation and difficult
procedures that require extensive dissection or lysis of adhesions are likely best
managed by the standard postoperative protocol.[30] The planned surgical procedure and FTP including risks and benefits are discussed
at this time with appropriate FTP patients.[30]
Perioperative β-blockade has been extensively studied in standard care perioperative
protocols. Current recommendations are to continue β-blockade in patients with known
coronary artery disease already on this therapy or those with preoperative cardiac
ischemia or cardiac symptoms scheduled to undergo high-risk surgery. When the decision
is made to initiate β-blockade therapy, it is started several weeks prior to surgery
and titrated to “appropriate and individual” heart rate and blood pressure. Patients
who continue or are placed on β-blockade therapy require close monitoring for bradycardiac
or hypotensive episodes in the postoperative period.[36]
[37]
Preoperative mechanical bowel preparation (MBP) was historically considered standard
procedure on the basis of the belief that it reduced infection rates and anastomotic
dehiscence by decreasing fecal and bacterial load. A recent Cochrane Review examined patients undergoing elective colon or rectal surgeries and found no evidence
of clinical benefit in prevention of anastomotic leaks or wound infections. In elective
extraperitoneal rectal surgery with restoration of continuity and patients undergoing
laparoscopic resection, the authors concluded that further research is required.[38] Recent guidelines from the Society of Alimentary Gastrointestinal Endoscopic Surgeons
recommend MBP in laparoscopic surgeries to improve bowel manipulation and prepare
for intraoperative colonoscopy if anastomotic visualization or lesion localization
is required. In lower rectal resections or rectal resections with planned proximal
diversion after resection and anastomosis, MBP is also recommended.[39]
[40] Currently, there are no studies that specifically address MBP in an FTP.
The Intraoperative Phase
The Pathophysiology of Surgical Stress
The surgical stress response is thought to be a conserved cellular defense mechanism
occurring as a result of surgical trauma.[41]
[42] This causes changes in neural, endocrine, and metabolic systems with a shift toward
catabolism, activation of sympathetic nervous system, and release of catecholamines.
When surgical injury is induced, afferent neuronal impulses are stimulated at the
site of injury and travel up sensory nerve roots through the dorsal horn of the spinal
cord to the medulla and hypothalamus. There is a subsequent release of hypothalamic
stimulating hormones and increased secretion of pituitary hormones, adrenocorticotropic
hormone, antidiuretic hormone, and growth hormones.[43] Increased secretion of these hormones shifts the body into a hyperdynamic and catabolic
state. This results in increased oxygen and cardiac demand, decreased pulmonary function,
pain, gastrointestinal (GI) side effects such as postoperative nausea and vomiting
(PONV) and ileus, derangements of coagulation favoring a prothrombotic state, and
immunosuppression.[7] Tissue injury also causes activation of the inflammatory response with local and
systemic effects. This is primarily mediated by cytokines, with an imbalance of proinflammatory
(interleukin- [IL-] 1, IL-6, and tumor necrosis factor-α) and anti-inflammatory cytokines,
with the magnitude of the stress response related to the degree of surgical trauma.[7]
[44]
[45] Proinflammatory cytokines also activate the hypothalamus–pituitary–adrenal axis.[44]
The overall goal of intraoperative components in fast-track surgery is attenuation
of surgical stress response. This is achieved either through blockade of inflammatory
or endocrine–metabolic responses. Standard intraoperative techniques to minimize or
block these responses include prevention of hypothermia, appropriate antibiotic prophylaxis,
and avoidance of blood transfusions. FTP interventions also include neuraxial blockade
and minimally invasive surgery.
Neuraxial Blockade and Preemptive Analgesia
Neuraxial blockade is an anesthetic technique providing optimal pain control by delivering
local and opioid analgesia directly to the dorsal horn of the spinal cord and decreasing
surgical stress response by blocking afferent neural impulses from the site of surgical
injury to the hypothalamus and anterior pituitary gland.[45]
[46] Epidural catheters have been shown to be superior to intravenous opioids in postoperative
pain control in both open and laparoscopic surgery.[47] There is also benefit shown in reduction of postoperative ileus (POI).[48] Yet, in the FTP setting, some studies did not find a benefit to use epidural anesthesia.
Other techniques for preemptive analgesia include systemic lidocaine or transabdominal
peritoneal block. Systemic lidocaine is generally administered intravenously with
bolus followed by continuous infusion to attenuate surgical stress response and prevention
of POI. A double-blind, randomized, placebo controlled trial found systemic lidocaine
infusions significantly decreased time to GI tract recovery (8 hours earlier than
control, p < 0.05) and length of stay (7 days in lidocaine group versus 8 days in control group,
p = 0.004) and attenuated elevated plasma levels of inflammatory cytokines.[49]
The transversus abdominis plane (TAP) block was first reported by Rafi in 2001 and
has since been modified several times.[50] Current technique involves infusion of local anesthetics into the neurovascular
plane between the transversus abdominis muscle and the internal oblique muscle via
the lumbar triangle of Petit. This regional anesthetic technique is capable of blocking
the lower intercostals (T7–11), iliohypogastrics, and ilioinguinal nerves. A prospective
randomized trial validated its ability to decrease postoperative opioid requirements
by 70% in 34 patients undergoing open elective colorectal surgeries.[51] Although TAP blocks hold much promise in reduction of postoperative pain, opioid
usage, and POI, more prospective randomized trials are needed to validate the above
studies' findings.
Minimally Invasive Surgery
Laparoscopy in colorectal surgery improves postoperative outcomes when compared with
an open approach, largely through decreased pulmonary complications, smaller incisions
resulting in decreased pain and opioid use, reduction in POI, and overall decreased
average length of stay by 2 to 3 days compared with conventional open surgery.[16]
[52]
[53] Recent Cochrane Reviews confirmed short-term benefits of laparoscopic colorectal surgery and long-term outcomes
of laparoscopic oncological resections.[54]
[55] Despite these findings, there is a slower rate of integration within the field of
colorectal surgery, with only a third of all elective colectomies in the United States
performed laparoscopically.
With introduction of FTPs into colorectal surgery, there is increasing interest in
further optimizing reduction of surgical stress, and its negative effects, by adopting
minimally invasive techniques. Single-center studies demonstrate a shorter length
of stay (3.7–4.1 d) with no increase in readmission or complication rates.[56]
[57]
[58] Poon et al found decreased rate of POI when evaluating colorectal cancer patients
undergoing laparoscopic colectomy with FTP, but did not find a statistically significant
difference in length of stay, complication, or readmission rates.[59]
There are also conflicting findings about cost-effectiveness. An English study reported
a significant reduction in length of stay compared with open procedures (5.2 vs. 7.4
d), but higher upfront operative costs ($4,016 vs. $2,781), which were offset by decreased
length of stay, readmission rates, and follow-up costs; the laparoscopic/FTP group
actually saved $517 ($9,405 vs. $9,922).[60] The traditional open, open fast-track recovery and laparoscopic fast-track multimodal
management (TAPAS) study is an ongoing prospective cohort study evaluating cost-effectiveness
of patients undergoing resection for colon cancer using laparoscopic techniques and
FTPs in three treatment arms (open surgery with standard treatment, open surgery with
fast-track treatment, and laparoscopic surgery with fast-track treatment). Primary
outcomes are direct medical costs and indirect nonmedical costs to direct the future
investment of minimally invasive techniques, FTPs, or a combination of both.[61]
To determine what the optimal combination of perioperative care is, several multicenter
trials have been undertaken. The laparoscopy and/or fast-track multimodal management
versus standard care (LAFA) study randomized patients with colon cancer to four different
arms: laparoscopic colectomy with fast-track care, laparoscopic colectomy with standard
care, open colectomy with fast-track care, or open colectomy with standard care. The
shortest length of stay occurred in the laparoscopic/FTP group, with laparoscopy the
only independent predictive factor to reduce length of stay and morbidity after regression
analysis.[62] Further multivariate and univariate analysis of baseline characteristics and fast-track
elements demonstrated early enteral feeding, early mobilization, laparoscopic surgery,
and female sex as independent determinants of early recovery.[63] The enhanced recovery open versus laparoscopic (EnROL) trial is an ongoing multicenter,
randomized control trial that stratifies patients to open or laparoscopic colorectal
cancer surgery with both groups receiving fast-track care. This trial seeks to determine
whether laparoscopic surgery improves outcomes compared with open surgery, even when
fast-track care is used. This trial differs from the LAFA study by including patients
undergoing resection for rectal carcinoma and excluding benign colorectal disease
to capture a sicker, older patient population who likely have a higher complication
rate and thus highlight potential benefits of laparoscopy and fast-track care.[64]
The use of minimally invasive surgery has also been explored in rectal surgery for
both benign and malignant disease.[65] The most recent recommendations published by the ERAS Society strongly recommend
laparoscopy in an FTP for resection of benign disease in the hands of an experienced
surgeon, but not for malignant disease unless in the setting of a trial until a final
consensus is reported from ongoing trials.[66]
Minimally invasive surgery is another fast-track surgery technique to decrease the
surgical stress response and improve patient outcomes. Although more costly upfront,
this is offset by decreased length of stay, inpatient resources, and postoperative
morbidity. There are multiple studies to support its use in colonic resections; however,
in rectal resections current evidence is limited at this time.
The Postoperative Phase
Recovery of Gastrointestinal Function
POI is a dreaded, but common complication after major abdominal surgery. POI is defined
as a “temporary impairment of GI function” and characterized by “bowel distension
and vomiting and delay in oral feeding and increased postoperative pain.”[52] The exact etiology of POI is unknown, but believed to be multifactorial with activation
of sympathetic reflexes at spinal and local levels and the inflammatory response.
Open surgery and increased bowel manipulation may contribute to POI. Laparoscopy,
as part of the FTP, is believed to reduce surgical trauma and the inflammatory response,
thus avoiding the development of POI; however, a Cochrane Review found laparoscopy can reduce but not prevent POI.[55] Cost of POI management is staggering with higher mean costs and length of stay with
an overall cost in the United States ranging from $750 million to $1.46 billion dollars.[67]
[68]
[69]
[70] FTPs attempt to lower incidence of POI by employing multimodal therapies. Current
protocols include minimally invasive surgery, thoracic epidural analgesia, avoidance
of routine nasogastric intubation, and early enteral feeding.
Judicious Pain Management
The postoperative phase is the most critical phase in increasing patient compliance
and decreasing length of stay. To that end, judicious and effective postoperative
pain management is crucial. Systemic opioids are a traditional part of pain management,
with excellent results seen with patient-controlled analgesia use; however, they are
not without their side effects including worsening of POI. The use of continuous epidural
analgesia, lidocaine infusions, and TAP blocks may represent methods to deliver effective
pain control and attenuate the surgical stress response and should be utilized in
fast-track surgery protocols.
Additional options for multimodality postoperative pain management are discussed in
the last article in this issue of Clinics in Colon and Rectal Surgery. These include regional, local infiltration (liposomal bupivacaine), and nonopioid
systemic analgesia (intravenous acetaminophen and nonsteroidal anti-inflammatory drugs).[71]
Future Directions
Since its inception in the mid-1990s, FTP continues to undergo refinement in an effort
to improve patient outcomes. Preoperative risk assessment is a cornerstone of all
successful surgical interventions. The tools and matrices that allow for careful assessment
and further optimization are based on conventional surgical protocols. As older and
sicker patients undergo surgery, further studies of these patients within an FTP are
needed to reassess perioperative risk.[72]
The overall reduction in surgical stress is a priority in FTP. Attenuation of this
response is an active area of research. Research into the efficacy of laparoscopy
in fully implemented FTPs is ongoing with the EnROL trial and results are expected
in the next year ([Table 1]).[64] Natural orifice transluminal endoscopic surgery and single-incision laparoscopic
surgery are the latest techniques in minimally invasive surgery, but their implementation
and benefit in FTP has yet to be investigated.[72]
Table 1
Laparoscopic colectomy with fast-track protocol
|
Author
|
Year
|
Total number of patients
|
No. of laparoscopic with FTP patients
|
Mean length of stay (days)
|
Complication rate (%)
|
Readmission rate (%)
|
|
Bardem et al[73]
|
2000
|
50
|
50
|
2.5
|
0.25
|
0.05
|
|
Basse et al[74]
|
2005
|
60
|
30
|
3.8
|
0.26
|
0.2
|
|
King et al[60]
|
2006
|
58
|
41
|
5.2
|
0.15
|
0.05
|
|
Delaney et al[53]
|
2008
|
118
|
118
|
3.7 ± 3.7
|
20.3
|
8.5
|
|
Reurings et al (TAPAs Trial)[61]
|
2010
|
120
|
40[a]
|
[b]
|
[b]
|
[b]
|
|
Vlug et al (LAFA Trial)[62]
|
2011
|
427
|
100
|
5 (4–8)[c]
|
34[d]
|
6[d]
|
|
Poon et al[59]
|
2011
|
180
|
96
|
4 (2–23)[c]
|
12.5[d]
|
5[d]
|
|
Delaney et al[57]
|
2012
|
1000
|
1000
|
4.1 ± 3.2
|
20
|
6
|
|
Kennedy et al (EnROL Trial)[64]
|
2012
|
202
|
133[a]
|
[b]
|
[b]
|
[b]
|
a Planned sample size.
b Ongoing trial.
c Median length of stay.
d Not significant, p > 0.05.
Conclusion
Fast-track surgery uses current evidence and multimodal therapies to reduce surgical
stress and enhance postoperative recovery by asking the simple question: Why is the
patient in the hospital today?[7] Whereas FTPs may encompass different individual components, each with varying reported
degrees of success, their overall usefulness is likely a reflection of the entire
protocol. What seems clear is that FTPs are safe and cost-effective, and result in
a reduction in both length of stay and postoperative morbidity and mortality. A successful
FTP is a multidisciplinary endeavor that requires support from all members of the
team, including the management of patients' expectations. Although full implementation
of all components continues to be a challenge, it is important to understand the evidence
behind their success. Many programs continue to exclude proven evidence-based components
such as proper patient information, utilization of neuraxial anesthesia, nonopioid
analgesia, or early enteral feeding.[72] These tools are proven to improve postoperative mobility and decrease risk of POI.
Although gains in the reduction of surgical stress, patient outcome, and cost have
been made, continuing reassessment and research is needed to further refine and improve
upon the components of the fast-track surgery protocol.
