UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Fast-track protocols in colorectal surgery

Authors
Rocco Ricciardi, MD, MPH
Graham MacKay, MBChB, FRCS, MD
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

Enhanced recovery, otherwise known as “fast-track” programs, are evidence-based protocols designed to standardize medical care, improve outcomes, and lower health care costs. Fast-track protocols for colorectal surgery patients were developed to reduce physiological stress and postoperative organ dysfunction through optimization of perioperative care and recovery [1]. Organization and effectiveness of a fast-track protocol requires participation and commitment from a multidisciplinary team, including surgeons, anesthesiologists, nursing staff, social services, and hospital administration.

BACKGROUND

Initially, fast-track surgery protocols converted many operations performed as inpatient to outpatient “day surgery” procedures. As experience developed with these protocols, the principles of enhanced recovery were applied to increasingly complex procedures to reduce hospital length of stay and expedite return to baseline health and functional status.

The goals of enhanced recovery protocols include attenuating the surgical stress response and reducing end organ dysfunction through integrated preoperative, intraoperative, and postoperative pathways. Discharge criteria with fast-track surgery are similar to those of traditional care, but fast-track programs meet the discharge criteria sooner [1].

DEFINITION

Fast-track surgery consists of a protocol of evidence-based techniques to reduce surgical trauma and postoperative stress by minimizing pain, reducing complications, improving outcomes, and decreasing hospital length of stay while expediting recovery following elective procedures.

ELEMENTS OF FAST-TRACK

Fast-track protocols include three elements combined to form a multimodal pathway:

                                  

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Jun 09 00:00:00 GMT 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Kehlet H, Wilmore DW. Fast-track surgery. Br J Surg 2005; 92:3.
  2. Wilmore DW, Kehlet H. Management of patients in fast track surgery. BMJ 2001; 322:473.
  3. Polle SW, Wind J, Fuhring JW, et al. Implementation of a fast-track perioperative care program: what are the difficulties? Dig Surg 2007; 24:441.
  4. Kahlet, H. Modification of responses to surgery by neural blockade: clinical implications. In: Neural Blockade in Clinical Anesthesia and Management of Pain, Cousins, MJ, Bridenbaugh, PO (Eds), Lippincott, Philadelphia 1998. p.129.
  5. Carli F, Charlebois P, Baldini G, et al. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can J Anaesth 2009; 56:837.
  6. Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2011; :CD001544.
  7. Dahabreh IJ, Steele DW, Shah N, Trikalinos TA. Oral Mechanical Bowel Preparation for Colorectal Surgery: Systematic Review and Meta-Analysis. Dis Colon Rectum 2015; 58:698.
  8. Scarborough JE, Mantyh CR, Sun Z, Migaly J. Combined Mechanical and Oral Antibiotic Bowel Preparation Reduces Incisional Surgical Site Infection and Anastomotic Leak Rates After Elective Colorectal Resection: An Analysis of Colectomy-Targeted ACS NSQIP. Ann Surg 2015; 262:331.
  9. Wick EC, Galante DJ, Hobson DB, et al. Organizational Culture Changes Result in Improvement in Patient-Centered Outcomes: Implementation of an Integrated Recovery Pathway for Surgical Patients. J Am Coll Surg 2015; 221:669.
  10. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology 2011; 114:495.
  11. Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev 2003; :CD004423.
  12. Brady M, Kinn S, Ness V, et al. Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst Rev 2009; :CD005285.
  13. Svanfeldt M, Thorell A, Hausel J, et al. Randomized clinical trial of the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein and glucose kinetics. Br J Surg 2007; 94:1342.
  14. Noblett SE, Watson DS, Huong H, et al. Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Dis 2006; 8:563.
  15. Smith MD, McCall J, Plank L, et al. Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 2014; :CD009161.
  16. Adam MA, Lee LM, Kim J, et al. Alvimopan Provides Additional Improvement in Outcomes and Cost Savings in Enhanced Recovery Colorectal Surgery. Ann Surg 2016; 264:141.
  17. White PF, Song D. New criteria for fast-tracking after outpatient anesthesia: a comparison with the modified Aldrete's scoring system. Anesth Analg 1999; 88:1069.
  18. White PF. Ambulatory anesthesia advances into the new millennium. Anesth Analg 2000; 90:1234.
  19. Lobo DN, Bostock KA, Neal KR, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 2002; 359:1812.
  20. Brandstrup B, Tønnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003; 238:641.
  21. Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth 2005; 95:634.
  22. MacKay G, Fearon K, McConnachie A, et al. Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. Br J Surg 2006; 93:1469.
  23. Phan TD, D'Souza B, Rattray MJ, et al. A randomised controlled trial of fluid restriction compared to oesophageal Doppler-guided goal-directed fluid therapy in elective major colorectal surgery within an Enhanced Recovery After Surgery program. Anaesth Intensive Care 2014; 42:752.
  24. Bundgaard-Nielsen M, Secher NH, Kehlet H. 'Liberal' vs. 'restrictive' perioperative fluid therapy--a critical assessment of the evidence. Acta Anaesthesiol Scand 2009; 53:843.
  25. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334:1209.
  26. Lenhardt R, Marker E, Goll V, et al. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology 1997; 87:1318.
  27. Carli F, Gabrielczyk M, Clark MM, Aber VR. An investigation of factors affecting postoperative rewarming of adult patients. Anaesthesia 1986; 41:363.
  28. Kurz A, Plattner O, Sessler DI, et al. The threshold for thermoregulatory vasoconstriction during nitrous oxide/isoflurane anesthesia is lower in elderly than in young patients. Anesthesiology 1993; 79:465.
  29. Kurz A, Sessler DI, Narzt E, et al. Morphometric influences on intraoperative core temperature changes. Anesth Analg 1995; 80:562.
  30. Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression after abdominal operations. Br J Surg 2005; 92:673.
  31. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ 2001; 323:773.
  32. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2007; :CD004929.
  33. Jørgensen H, Wetterslev J, Møiniche S, Dahl JB. Epidural local anaesthetics versus opioid-based analgesic regimens on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery. Cochrane Database Syst Rev 2000; :CD001893.
  34. Lourenco T, Murray A, Grant A, et al. Laparoscopic surgery for colorectal cancer: safe and effective? - A systematic review. Surg Endosc 2008; 22:1146.
  35. Novitsky YW, Litwin DE, Callery MP. The net immunologic advantage of laparoscopic surgery. Surg Endosc 2004; 18:1411.
  36. Kehlet H. Surgical stress response: does endoscopic surgery confer an advantage? World J Surg 1999; 23:801.
  37. Shea JA, Berlin JA, Bachwich DR, et al. Indications for and outcomes of cholecystectomy: a comparison of the pre and postlaparoscopic eras. Ann Surg 1998; 227:343.
  38. Fleshman J, Sargent DJ, Green E, et al. Laparoscopic colectomy for cancer is not inferior to open surgery based on 5-year data from the COST Study Group trial. Ann Surg 2007; 246:655.
  39. MacKay G, Ihedioha U, McConnachie A, et al. Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery. Colorectal Dis 2007; 9:368.
  40. King PM, Blazeby JM, Ewings P, et al. Randomized clinical trial comparing laparoscopic and open surgery for colorectal cancer within an enhanced recovery programme. Br J Surg 2006; 93:300.
  41. Mamidanna R, Burns EM, Bottle A, et al. Reduced risk of medical morbidity and mortality in patients selected for laparoscopic colorectal resection in England: a population-based study. Arch Surg 2012; 147:219.
  42. Lei QC, Wang XY, Zheng HZ, et al. Laparoscopic Versus Open Colorectal Resection Within Fast Track Programs: An Update Meta-Analysis Based on Randomized Controlled Trials. J Clin Med Res 2015; 7:594.
  43. Aytac E, Stocchi L, Ozdemir Y, Kiran RP. Factors affecting morbidity after conversion of laparoscopic colorectal resections. Br J Surg 2013; 100:1641.
  44. Souter AJ, Fredman B, White PF. Controversies in the perioperative use of nonsterodial antiinflammatory drugs. Anesth Analg 1994; 79:1178.
  45. Zutshi M, Delaney CP, Senagore AJ, Fazio VW. Shorter hospital stay associated with fastrack postoperative care pathways and laparoscopic intestinal resection are not associated with increased physical activity. Colorectal Dis 2004; 6:477.
  46. Kamel HK, Iqbal MA, Mogallapu R, et al. Time to ambulation after hip fracture surgery: relation to hospitalization outcomes. J Gerontol A Biol Sci Med Sci 2003; 58:1042.
  47. Wren SM, Martin M, Yoon JK, Bech F. Postoperative pneumonia-prevention program for the inpatient surgical ward. J Am Coll Surg 2010; 210:491.
  48. MacKay GJ, Molloy RG, O'Dwyer PJ. C-reactive protein as a predictor of postoperative infective complications following elective colorectal resection. Colorectal Dis 2011; 13:583.
  49. Lane JC, Wright S, Burch J, et al. Early prediction of adverse events in enhanced recovery based upon the host systemic inflammatory response. Colorectal Dis 2013; 15:224.
  50. Hendren S, Morris AM, Zhang W, Dimick J. Early discharge and hospital readmission after colectomy for cancer. Dis Colon Rectum 2011; 54:1362.
  51. Pritts TA, Nussbaum MS, Flesch LV, et al. Implementation of a clinical pathway decreases length of stay and cost for bowel resection. Ann Surg 1999; 230:728.
  52. Basse L, Hjort Jakobsen D, Billesbølle P, et al. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000; 232:51.
  53. Basse L, Thorbøl JE, Løssl K, Kehlet H. Colonic surgery with accelerated rehabilitation or conventional care. Dis Colon Rectum 2004; 47:271.
  54. Delaney CP, Fazio VW, Senagore AJ, et al. 'Fast track' postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 2001; 88:1533.
  55. Kariv Y, Delaney CP, Senagore AJ, 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; 50:137.
  56. Muller S, Zalunardo MP, Hubner M, et al. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Gastroenterology 2009; 136:842.
  57. Wind J, Polle SW, Fung Kon Jin PH, et al. Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 2006; 93:800.
  58. Kennedy RH, Francis EA, Wharton R, et al. Multicenter randomized controlled trial of conventional versus laparoscopic surgery for colorectal cancer within an enhanced recovery programme: EnROL. J Clin Oncol 2014; 32:1804.
  59. Proske JM, Raue W, Neudecker J, et al. [Fast track rehabilitation in colonic surgery: results of a prospective trial]. Ann Chir 2005; 130:152.
  60. Delaney CP, Zutshi M, Senagore AJ, et al. Prospective, randomized, controlled trial between a pathway of controlled rehabilitation with early ambulation and diet and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 2003; 46:851.
  61. Anderson AD, McNaught CE, MacFie J, et al. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 2003; 90:1497.
  62. Kremer M, Ulrich A, Büchler MW, Uhl W. Fast-track surgery: the Heidelberg experience. Recent Results Cancer Res 2005; 165:14.
  63. Susa A, Roveran A, Bocchi A, et al. [FastTrack approach to major colorectal surgery]. Chir Ital 2004; 56:817.
  64. Smedh K, Strand E, Jansson P, et al. [Rapid recovery after colonic resection. Multimodal rehabilitation by means of Kehlet's method practiced in Vasteras]. Lakartidningen 2001; 98:2568.
  65. Gatt M, Anderson AD, Reddy BS, et al. Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 2005; 92:1354.
  66. Nicholson A, Lowe MC, Parker J, et al. Systematic review and meta-analysis of enhanced recovery programmes in surgical patients. Br J Surg 2014; 101:172.
  67. Lawrence JK, Keller DS, Samia H, et al. Discharge within 24 to 72 hours of colorectal surgery is associated with low readmission rates when using Enhanced Recovery Pathways. J Am Coll Surg 2013; 216:390.
  68. Zhuang CL, Ye XZ, Zhang XD, et al. Enhanced recovery after surgery programs versus traditional care for colorectal surgery: a meta-analysis of randomized controlled trials. Dis Colon Rectum 2013; 56:667.
  69. Greco M, Capretti G, Beretta L, et al. Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials. World J Surg 2014; 38:1531.
  70. Li LT, Mills WL, Gutierrez AM, et al. A patient-centered early warning system to prevent readmission after colorectal surgery: a national consensus using the Delphi method. J Am Coll Surg 2013; 216:210.
  71. DiFronzo LA, Yamin N, Patel K, O'Connell TX. Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg 2003; 197:747.
  72. Wind J, Hofland J, Preckel B, et al. Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial). BMC Surg 2006; 6:16.
  73. Reurings JC, Spanjersberg WR, Oostvogel HJ, et al. A prospective cohort study to investigate cost-minimisation, of Traditional open, open fAst track recovery and laParoscopic fASt track multimodal management, for surgical patients with colon carcinomas (TAPAS study). BMC Surg 2010; 10:18.
  74. Slim K, Fingerhut A. Laparoscopy or fast-track surgery, or both? Surg Endosc 2009; 23:465.
  75. Basse L, Madsen JL, Kehlet H. Normal gastrointestinal transit after colonic resection using epidural analgesia, enforced oral nutrition and laxative. Br J Surg 2001; 88:1498.
  76. Basse L, Raskov HH, Hjort Jakobsen D, et al. Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 2002; 89:446.
  77. Jakobsen DH, Sonne E, Andreasen J, Kehlet H. Convalescence after colonic surgery with fast-track vs conventional care. Colorectal Dis 2006; 8:683.
  78. Behm B, Stollman N. Postoperative ileus: etiologies and interventions. Clin Gastroenterol Hepatol 2003; 1:71.
  79. Kehlet H. Fast-track colonic surgery: status and perspectives. Recent Results Cancer Res 2005; 165:8.