Original ArticleFast-track in open intestinal surgery: Prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456)
Introduction
Advances in perioperative care have often been described in the literature over the past 10 years, with emphasis on the positive effect of enhanced perioperative care on results of surgical treatment.1, 2, 3, 4, 5, 6, 7, 8 A combination of perioperative interventions, the aim of which is to reduce postoperative stress, frequency of postoperative complications, and length of hospital stay, is usually called accelerated postoperative rehabilitation or fast-track. It is basically a multidisciplinary perioperative care strategy in which anesthesiologists, surgeons, dieticians, and physiotherapists participate.9, 10 Education of the patient during postoperative care is also crucial as well as their active participation in the process of postoperative recovery. Fast-track postoperative care is derived from evidence-based medicine as an alternative to the dogma of empirical non-evidence-based procedures. A large number of surgical departments, however, continue to apply standard procedures.11
The aim of our prospective randomized study was to prove that our fast-track protocol was safe, improved the patient's analgesic care, enabled faster restoration of gastrointestinal (GI) functions, improved postoperative results, and shortened length of hospitalization in comparison with the standard care. The study aim was also to see whether significant reduction of length of hospital stay could be achieved in Central Europe, where there is a tradition of much longer length of hospital stay.
Section snippets
Patients and method
This prospective, monocentric, unblinded, randomized study included all patients scheduled for open intestinal resection, with or without stomy, during the period April 2005–December 2007. All eligible patients were enrolled in the study if they were in the age group 18–70 years and were scored ASA I–II. It was presumed that selection of patients with low polymorbidity would lead to better cooperation and easier interdisciplinary coordination during introduction of the new method and therefore
Results
Of 105 enrolled patients (53 in the FT group and 52 in the non-FT group), 103 were assessed (51 in the FT group and 52 in the non-FT group).
Patients' characteristics are summarized in Table 1. Patients in both groups did not differ statistically in age and diagnosis. There were more females in the FT group. Most patients were operated on for IBD as our department focused on this disease. Inclusion of only patients with low morbidity resulted in a majority of this diagnosis. Our department does
Discussion
Protocols of accelerated recovery differ and each uses a different EBM tool combination.1, 2, 3, 4, 5, 6, 7, 8 Our protocol emphasized education of the patient, maintaining anesthesia and accurate analgesia using PCA epidural analgesia, fast rehabilitation, and restriction of oral intake for as short a period as possible. Significant positive results changed our approach to postoperative care.
One of the aims of our prospective randomized study was to create our own protocol that could be
Conclusion
We concluded that our protocol is safe for patients after bowel resection. There was significantly better control of postoperative pain. Postoperative rehabilitation according to the protocol was faster, as was restoration of regular oral intake. GI functions were also restored sooner, which may be associated with forced early oral intake, more frequent time spent out of bed, and opiate sparing analgesic procedures. Lower frequency of postoperative complications may be the result of
Conference presentation
- 1.
The 13th congress of Czech Society of Anesthesia, Pilsen, Czech Republic, 2006.
- 2.
Czech gastroenterological days, Karlovy Vary, Czech Republic, 2006.
- 3.
The 11th Central European Congress of Coloproctology, Graz, Austria, 2006.
- 4.
Accelerated Postoperative Rehabilitation including Early Oral Feeding, the 28th ESPEN Congress, Istanbul, 2006.
- 5.
The 2nd International Forum on Pain Medicine, 2006, Guadalajara, Mexico.
- 6.
The 42nd World Congress of Surgery of the International Society of Surgery ISS/SIC,
Conflict of interest
All listed authors (Z. Šerclová, P. Dytrych, J. Marvan, K. Nová, Z. Hankeová, O. Ryska, Z. Šlégrová, L. Trávníková, F. Antoš) didn't have any conflict of interest to disclose.
Acknowledgments
1. The study was supported by the State Grant Agency – Internal Grant Agency of the Ministry of Health. The study design was developed by the named authors and a successful bid for funding was made. The grant sources supported completion of the actual project including collection and analysis of data. Publication of project results was requested by the Agency. Grant No: IGA MZ CR NR 84-20-3.
2. Prof. MUDr. Zdenek Zadak, Dr.Sc. reviewed the preliminary draft. Victor W. Fazio, MD, Prof. reviewed
References (27)
- et al.
Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection
Clin Nutr
(2005) - et al.
ESPEN guidelines on enteral nutrition: surgery including organ transplantation
Clin Nutr
(2006) - et al.
Randomized controlled trial comparing the controlled rehabilitation with early ambulation and diet pathway versus the controlled rehabilitation with early ambulation and diet with preemptive epidural anesthesia/analgesia after laparotomy and intestinal resection
Am J Surg
(2005) - et al.
Perioperative fluid restriction reduces complications after major gastrointestinal surgery
Surgery
(2008) Fluid therapy for the surgical patient
Best Pract Res Clin Anaesthesiol
(2006)- et al.
Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study
Br J Anaesth
(2007) Fast-track colonic surgery: status and perspectives
Recent Results Cancer Res
(2005)- et al.
Optimizing perioperative management of patients undergoing colorectal surgery: what is new?
Curr Opin Crit Care
(2006) - et al.
“Fast-track” rehabilitation after rectal cancer resection
Int J Colorectal Dis
(2006) - et al.
Clinical outcomes and cost analysis of a “fast track” postoperative care pathway for ileal pouch-anal anastomosis: a case control study
Dis Colon Rectum
(2007)
“Fast-track” rehabilitation after colonic surgery in elderly patients – is it feasible?
Int J Colorectal Dis
Perioperative strategy in colonic surgery; Laparoscopy and/or Fast track multimodal management versus standard care (LAFA trial)
BMC Surg
A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer
Ann Surg
Cited by (109)
Carbohydrate loading and fluid management within enhanced recovery
2021, Seminars in Colon and Rectal SurgeryCitation Excerpt :Numerous studies have demonstrated that ERP measures are effective in maintaining anabolic homeostasis and improving postoperative outcomes, including decreasing mortality, hospital LOS, postoperative complications, readmission rates and hospital costs.3,17,21,22 Studies of major colorectal surgical patients, including large meta-analyses, have repeatedly found that ERPs improve recovery, decreasing LOS23 and morbidity.21,24-28 ERPs include elements of preoperative preparation, fluid management, anesthesia and analgesia, and perioperative nutrition and mobilization.2
The benefits of enhanced recovery after surgery for gastric cancer: A large before-and-after propensity score matching study
2021, Clinical NutritionCitation Excerpt :To avoid readmission after hospital discharge, appropriate hospital discharge decisions based on objective discharge criteria may be helpful for patients who undergo ERAS [23]. Improved morbidity is well documented in several RCTs that have examined ERAS after colorectal surgery [24–26]. However, the benefit of ERAS to reduce postoperative morbidity is uncertain for gastrectomy.
Quality Versus Costs Related to Gastrointestinal Surgery: Disentangling the Value Proposition
2020, Journal of Gastrointestinal SurgeryThe application of lean management in the perioperative care of patients with colon cancer
2023, Archives of Hellenic Medicine