Behind The Medical Headlines

Fast-track surgery and enhanced recovery

• Mr D Alcorn, Consultant Anaesthetist, Department of Anaesthesia, Royal Alexandra Hospital, Paisley, UK
• Mr A Renwick, Consultant Colorectal Surgeon, Department of Surgery, Royal Alexandra Hospital, Paisley, UK

Summary

Fast-track surgery and enhanced recovery after surgery are programmes that aim to reduce the physical trauma of surgery and achieve a complication-free recovery, thereby shortening hospital stays for patients. Mr David Alcorn and Mr Andrew Renwick explain the elements and procedures involved.

Declaration of interests: No conflict of interests declared

Introduction

Enhanced recovery after surgery (ERAS) is a relatively new method of patient management. It is a collection of strategies that combine in a structured pathway allowing the surgical and anaesthetic teams to decrease the physical insult and aid recovery enabling earlier discharge. This is achieved with fewer complications. Fast-track (FT) programmes originated in Denmark,¹ but now are being taken up worldwide. Many specialties have undertaken such programmes, but this approach is rapidly developing in colonic and rectal surgery.

Fast-track programmes reduce the length of hospital stay in several ways but, for colorectal surgery, many of these are targeted at maintaining normal gut physiology. Surgical dogma in colorectal practice has previously led many to believe that surgery should be performed on a well-prepped bowel in a fully fasted patient, with a nasogastric (NG) tube in situ and a stepwise introduction of fluids prior to the introduction of diet. Such teaching, however, has been increasingly challenged in surgical practice of late.² Evidence has been presented which strongly suggests that such an approach prolongs the length of stay of the patient.

Key elements

While some of the following are active administrations of new modalities, there are others that seek to reduce complications by minimising the effect of preparation for surgery, and the surgery itself, on the gut.³ The 17 key elements which set ERAS programmes apart are:

1. Preoperative counselling
2. Preoperative feeding (up to two hours prior to surgery)
3. No bowel preparation
4. No premedication
5. Fluid restriction (or at least optimisation)
6. Perioperative high oxygen concentration
7. Active prevention of hypothermia
8. Epidural analgesia
9. Laparoscopic or minimally-invasive incisions
10. No routine use of NG tubes
11. No routine use of drains
12. Enforced postoperative mobilisation
13. No systemic morphine use
14. Standard laxatives
15. Early removal of urinary catheters
16. DVT prophylaxis
17. Enhanced preoperative and postoperative nutrition via supplements

Changing expectations and practice

The effectiveness of an ERAS programme depends on changing patients’ expectations for their hospital stay. Encouraging them to expect a reduced stay, with a shorter, complication-free recovery, is easily accepted. Additionally, a full explanation of each part of the process, backed up with clear, easy-to-understand written material, helps to manage patients’ expectations.

The first break from traditional care is the omission of bowel preparation.² A dehydrated patient results in a dehydrated bowel, and there is no evidence that bowel preparation is of any benefit. To decrease dehydration, preoperative feeding with glucose-containing fluids is allowed up to two hours before surgery, thus maintaining gut function for as long as is possible.

Premedication is of less importance with the advent of modern anaesthetic techniques and drugs. The problem of giving benzodiazepines – the most common premed – is that their half-life is considerably longer than that of newer volatiles or propofol, rendering the patient sleepy and unable to sit up in bed, and therefore unable to breathe as deeply or drink as normal.

Prior to anaesthesia, an epidural is sited in the lower thoracic region. This will provide analgesia for the operation itself and for the first 48 hours following theatre. Minimising the need for systemic morphine (and its many debilitating side effects) maintains gut peristalsis throughout surgery because of the sympathetic blockade from the epidural, thereby also helping gut homeostasis.⁴

Fast track in the theatre

Within theatre, a high concentration of oxygen given to the patient has the effect of minimising small vessel hypoxia. This results not only in lower infection and anastomotic leak rates but also in the faster resumption of a full diet and thus normal function. At the same time, active warming by air and fluid routes maintains the patient’s core and peripheral temperature as close to normal as possible. This has the effect of maintaining immune function, preserving normal blood coagulation and preventing hypothermia and myocardial ischaemia.

Intravenous fluids given in theatre are extremely important as their function is to prevent secondary dehydration while the operation is proceeding. Judicious fluid administration can minimise renal impairment and cognitive dysfunction, as well as surgical complications. The use of oesophageal Doppler and LiDCO cardiac monitors has shown a reduction in morbidity and length of stay after major surgery.⁵ The concept of fluid-restrictive regimens in preventing gut oedema from fluid overload may be counter-productive, and there is evidence that more fluid (especially synthetic colloids) given appropriately under Doppler control can further reduce the length of stay by two days. Some studies cite evidence that restrictive fluid regimens are advantageous, but closer examination shows these ‘restricted’ regimens used different fluids (usually colloids) to suggest the appearance of less fluid.

Aiding recovery

While the anaesthetic team works to achieve physiological equilibrium, the surgeon attempts to minimise trauma by using transverse incisions or newer laparoscopic approaches to decrease surgical insult. The National Institute for Health and Clinical Excellence⁶ now recognises that such techniques are beneficial to patients’ recovery, with a recommendation that all primary cancers be considered for laparoscopic excision. Dissection is within anatomical planes using a power source to avoid blood loss. Drains are avoided wherever possible, as are nasogastric tubes. Urinary catheters are removed as soon as possible, thus enabling early mobilisation. This is aided in the immediate postoperative period, as the anaesthetist has rendered the patient comfortable, nausea-free, alert and awake, and as a result able to take diet and mobilise on the night of operation.

Further reading

Maessen J, Dejong CHC, Hausel J et al. A protocol is not enough to implement an enhanced recovery programme for colorectal resection. Br J Surg 2007; 94(2):224–31.

References

1. Holte K, Kehlet H. Postoperative ileus: progress towards effective management. Drugs 2002; 62(18):2603–15.
2. Guenaga KF, Atallah AN, Castro AA et al. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2003; 2:CD001544. Update in Cochrane Database Syst Rev 2005; 1:CD001544.
3. Pearse R, Dawson D, Fawcett D et al. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care 2005; 9:R687–93.
4. Senagore AJ, Delaney CP, Mekhail N et al. Randomized clinical trial comparing epidural anaesthesia and patient-controlled analgesia after laparoscopic segmental colectomy. Br J Surg 2003; 90(10):1195–9.
5. Noblett SE, Snowden CP, Shenton BK et al. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg 2006; 93(9):1069–76.
6. NICE. Laparoscopic surgery for the treatment of colorectal cancer (TA105). London: NICE; 2006.