Elsevier

Clinical Nutrition

Volume 28, Issue 6, December 2009, Pages 618-624
Clinical Nutrition

Original Article
Fast-track in open intestinal surgery: Prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456)

https://doi.org/10.1016/j.clnu.2009.05.009Get rights and content

Summary

Background

Studies have shown the value of using fast-track postoperative recovery. Standard procedures (non-fast-track strategies) remain in common use for perioperative care. Few prospective reports exist on the outcome of fast-tracking in Central Europe. The aim of our study was to assess the effect and safety of our own fast-track protocol with regard to the postoperative period after open bowel resection.

Patients and methods

One hundred and five patients with ASA score I–II scheduled for open intestinal resection in the period April 2005–December 2007 were randomly selected for the fast-track group (FT) and non-fast-track group (non-FT). A designed protocol was used in the FT group with the emphasis on an interdisciplinary approach. The control group (non-FT) was treated by standard established procedures. Postoperative pain, rehabilitation, gastrointestinal functions, postoperative complications, and post-op length of stay were recorded.

Results

Of 105 patients, 103 were statistically analyzed. Patients in the FT group (n = 51) and non-FT group (n = 52) did not differ in age, surgical diagnosis, or procedure. The fast-track procedure led to significantly better control of postoperative pain and faster restoration of GI functions (bowel movement after 1.3 days vs. 3.1, p < 0.001). Food tolerance was significantly better in the FT group and rehabilitation was also faster. Hospital stay was shorter in the FT group – median seven days (95% CI 7.0–7.7) versus ten days (95% CI 9.5–11.3) in non-FT (p < 0.001). Postoperative complications within 30 postoperative days were also significantly lower in the FT group (21.6 vs. 48.1%, p = 0.003). There were no deaths and no patients were readmitted within 30 days.

Conclusions

Following the FT protocol helped to reduce frequency of postoperative complications and reduced hospital stay. We conclude that the FT strategy is safe and effective in improving postoperative outcomes.

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

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