Gastroenterology

Gastroenterology

Volume 136, Issue 3, March 2009, Pages 842-847.e1
Gastroenterology

Clinical—Alimentary Tract
A Fast-Track Program Reduces Complications and Length of Hospital Stay After Open Colonic Surgery

https://doi.org/10.1053/j.gastro.2008.10.030Get rights and content

Background & Aims

A fast-track program is a multimodal approach for patients undergoing colonic surgery that combines stringent regimens of perioperative care (fluid restriction, optimized analgesia, forced mobilization, and early oral feeding) to reduce perioperative morbidity, hospital stay, and cost. We investigated the impact of a fast-track protocol on postoperative morbidity in patients after open colonic surgery.

Methods

A randomized trial of patients in 4 teaching hospitals in Switzerland included 156 patients undergoing elective open colonic surgery who were assigned to either a fast-track program or standard care. The primary end point was the 30-day complication rate. Secondary end points were severity of complications, hospital stay, and compliance with the fast-track protocol.

Results

The fast-track protocol significantly decreased the number of complications (16 of 76 in the fast-track group vs 37 of 75 in the standard care group; P = .0014), resulting in shorter hospital stays (median, 5 days; range, 2–30 vs 9 days, respectively; range, 6–30; P < .0001). There was a trend toward less severe complications in the fast-track group. A multiple logistic regression analysis revealed fluid administration greater than the restriction limits (odds ratio, 4.198; 95% confidence interval, 1.7–10.366; P = .002) and a nonfunctioning epidural analgesia (odds ratio, 3.365; 95% confidence interval, 1.367–8.283; P = .008) as independent predictors of postoperative complications.

Conclusions

The fast-track program reduces the rate of postoperative complications and length of hospital stay and should be considered as standard care. Fluid restriction and an effective epidural analgesia are the key factors that determine outcome of the fast-track program.

Section snippets

Patients and Eligibility

We conducted a multicenter, randomized trial in 4 surgical departments (teaching hospitals) in Switzerland. Eligible for this trial were patients older than 18 years of age who were undergoing open elective colonic resection with a primary anastomosis. Exclusion criteria were emergency situations, contraindication to epidural anesthesia, scheduled total colectomy or rectum resection, and preoperatively immobile patients. The study was approved by the local ethical committees of the

Results

From November 2004 until October 2006 there were 156 patients who fulfilled inclusion criteria and were assigned randomly to the fast-track and standard care groups. A planned interim analysis was performed after inclusion of one third of the calculated sample size and the study was stopped prematurely after reaching a significant difference for the primary end point according to the O'Brien–Fleming approach. Thus, 151 patients completed the study period (supplementary Table 1; see

Discussion

The results of this randomized multicenter trial indicate that a fast-track program significantly reduces the number of postoperative complications, especially general complications, leading to a shorter hospital stay after elective open colonic surgery. In a multivariate analysis, the present study shows that intraoperative fluid restriction and an effective EDA are significant predictors of reduced postoperative complications. Methodologic limitations of this study, which may cause a bias of

Investigators of the Zurich Fast Track Trial Group

Sven Muller, MD, and Nicolas Demartines, MD, Department of Visceral Surgery, CHUV, Lausanne, and formerly Visceral and Transplant Surgery, University Hospital Zurich; Pierre A. Clavien, MD, PhD, Visceral and Transplant Surgery, University Hospital Zurich; Marco P. Zalunardo, MD, Institute of Anesthesiology, University Hospital Zurich; Marco Decurtins, MD, Department of Surgery, Kantonsspital Winterthur; Lukas Eisner, MD, Department of Surgery, Kantonsspital Olten; Italo Castelli, MD, Department

Acknowledgements

Members of the Zurich Fast Track Study Group are listed at the end of the article.

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    Trial Registration: http://www.clinicaltrials.gov; identifier: NCT00556790.

    Dr Muller designed the study, analyzed the data, performed statistical analysis and drafted the manuscript and had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Zalunardo, Dr Hubner, and Dr Clavien participated in the design and coordination of the study and data analyses and helped to draft the manuscript. Dr Demartines designed the study, analyzed the data, and helped to draft the manuscript. All authors read and approved the final manuscript.

    Conflicts of interest The authors disclose the following: Dr Muller, Dr Clavien, and Dr Demartines have received research support from Fresenius Kabi, Stans, Switzerland. Dr Zalunardo and Dr Hubner disclose no conflicts.

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