World J Surg (2012) 36:2473–2480 DOI 10.1007/s00268-012-1690-1

Fast-Track for the Modern Colorectal Department Rishabh Sehgal • Arnold Hill • Joseph Deasy Deborah A. McNamara • Ronan A. Cahill

•

Published online: 27 June 2012 Ó Socie´te´ Internationale de Chirurgie 2012

Abstract In recent years, fast-track or enhanced recovery after surgery (ERAS) colorectal pathways have been utilized to achieve faster recovery and discharge from hospital with swift resumption of normal activities of daily living without an increase in complications or readmissions. Despite the large body of evidence available, however, adoption of the fast-track methodology in current surgical practice has been slow and sporadic. As outlined by a recent Cochrane review, practice uptake has mostly focused on individual component uptake. Therefore, instead of repeating what already has been established in the literature pertaining to colorectal fast-track surgery, the aim of this article is to interrogate the evidence concerning the individual components of ERAS pathways as they relate to a contemporary surgical department to determine the most relevant critical components for patients undergoing colorectal surgery in modern surgical practice.

Introduction Traditionally, patients undergoing elective or semielective open colorectal resection were required to remain R. Sehgal (&) Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin 2, Ireland e-mail: [email protected] A. Hill Department of Surgery, Beaumont Hospital, Dublin 9, Ireland J. Deasy
D. A. McNamara
R. A. Cahill Department of Colorectal Surgery, Beaumont Hospital, Dublin 9, Ireland e-mail: [email protected]

hospitalized and observed for the development of complications [1]. Rehabilitation toward baseline function was slow and stepwise over 8 to 14 days before discharge [2]. There was a further prolongation of hospital stay in that 15–20 % of patients developed complications, with an additional 6–10 inpatient-days, on top of the associated morbidity and distress. Inevitably, such care represented a significant financial burden to the health care system [3, 4]. Numerous studies have since indicated that many traditional perioperative care practices are unnecessary and even detrimental [2, 5], leading to the introduction of multimodal, multidisciplinary-team accelerated rehabilitation regimens that comprise ‘‘package of care pathways’’ [6–8]. Such ‘‘fast-track’’ protocols (also known as enhanced recovery after surgery, or ERAS) reduce the stress and injury associated with the planned operation and have been shown to reduce both postoperative complications and hospital stay to as low as a median of 2 days [9] or 23 h [10] after open and laparoscopic colectomy, respectively. However, even as these pathways have been developed and implemented, contemporary colorectal departments have subspecialized away from their general surgery roots and further modernized their perioperative practices independent of such programs. They have introduced advanced minimally invasive surgical techniques (notably single-port and multiple-port laparoscopy and combined laparoendoscopic approaches) into routine practice. This has led some to challenge the rationale behind implementing the entire fast-track package, choosing instead to cherry-pick certain components. Furthermore, different departments possess different specific skill sets and expertise as well as different distinct patient demographics, confounding ‘‘one size fits all’’ recipes. The aim of this article is to interrogate the evidence concerning the individual components of ERAS

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pathways as they pertain to a contemporary colorectal surgical department to determine the most relevant components.

Evidence base Fast-track proponents detail more than 20 components necessary to optimize postoperative recovery and minimize the hospital stay (Fig. 1). They frequently stress the need for evidence-based, rather than empirical care. However, the specific data underlying each one in isolation is in some cases limited, and ERAS studies mostly focus on outcomes after ‘‘package adoption.’’ There is even considerable component variability in the six randomized control trials in this area, and none utilized every component [11–16] (Table 1). Preoperative counseling, feeding and avoidance of bowel preparation were common to all these trials, with epidural anesthesia being the most common perioperative element. Most of the trials focused on postoperative components, avoiding routine use of nasogastric tubes and systemic morphine and employing early mobilization and feeding. Such selectivity was highlighted by a recent Cochrane review, which concluded that the overall quality of evidence was low, and certain factors (e.g., laparoscopic approaches) were nearly totally unaddressed [17]. This is not perhaps surprising as surgical technique is a dynamic entity that has evolved considerably in the decade since enhanced recovery programs were initiated. Laparoscopic surgery is more standardized now than previously

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(including postgraduate and postconsultancy mentorship programs), and there is much more specialization by surgeons, anesthetists, and nurse practitioners. Nonetheless, there is a general consensus that ERAS programs are beneficial for patients (as demonstrated by two recent meta-analyses [18, 19]) and that there is a ‘‘dose–response’’ relation with the degree of adherence to the protocols [20]. Also departmental processes and practices are streamlined and simplified.

Multidisciplinary team To implement a successful colorectal fast-track rehabilitation program, an engaged, enthusiastic cross-disciplinary team comprising surgeons, anesthetists, specialist nurses (including stoma therapists and pain and oncology nurse practitioners), dieticians, physiotherapists, operating theatre staff, and perhaps most importantly ward staff is essential. It is imperative that all appreciate the overarching goal and understand their individual roles in achieving it. Indeed, anecdotally and empirically the most useful and long-lasting beneficial impact of ERAS programs is the improved communication and understanding among allied members of the staff. The platform that develops enables improved facility for research and audit-based work as well as innovation introduction. The most crucial elements in the entire fast-track process, however, are patients for whom every effort should be made to motivate, educate, and empower to take an active role in their own recovery. Clear instructions, explanations, and a proposed timeline outlining key convalescence milestones should be given, including visual aids such as videos, booklets, and perhaps web-based care pathways that not only explain the operative procedure but also what the entire hospital stay entails [21]. Furthermore, patients should be encouraged to contact specialist nurses via phone or e-mail should they have any questions and concerns. Such measures increase the patient’s perception of being in control and reduce their level of anxiety and even postoperative pain, narcotic requirements, and hospital stay [22–28]. Equally, such steps improve the consent process and engage patients and family members more fully in the surgical process.

Preoperative patient selection and optimization

Fig. 1 Salient components of a fast-track program pathway. (From Tjandra and Chan [4], with permission)

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Aside from the opportunity to provide education and counseling, preoperative assessment encompasses an extensive medical evaluation to identify and optimize any co-morbidities and risk factors that may hinder the patient’s progress. Although not often formally included in

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Table 1 Summary of randomized controlled clinical trials evaluating fast-track protocols versus conventional treatment in patients undergoing colorectal surgery Study

No.

Age (years)

Sex (M:F)

BMI

POSSUM

ASA (1/2/3)

No. of FT components used

FT

Control

FT

Control

FT

Control

FT

Control

FT

Control

FT

Control

Anderson [11]

14

11

64.0

68.0

6/8

5/6

26

24

26

26

13/1a

10/1

Delaney [12]

31

33

30.6

41.9

21/10

21/12

NA

NA

NA

NA

3/16/12

0/26/7

4

Gatt [13] Khoo [14]

19 35

20 35

67.0 69.3

67.0 73.0

9/10 12/23

14/6 15/20

24 NA

27 NA

13 NA

12 NA

2b 5/25/5

2b 3/27/5

12 8

Muller [15] Serclova´ [16]

76

75

62.0

59.0

37/39

40/35

24

26

NA

NA

2/50/24

3/54/18

9

51

52

35.1

37.6

20/31

32/20

NA

NA

NA

NA

NA

NA

12

10

FT fast-track; BMI body mass index; POSSUM physiological and operative severity score for the enumeration of morbidity and mortality (study); ASA American Society of Anesthesiologists; NA not available a

ASA 1 and 2 taken together

b

ASA depicted as the median

fast-track programs, the platform provides an opportunity for nutritional optimization including correction of anemia, iron, and vitamin B12 stores (commonly depleted in patients with cancer or inflammatory bowel disease). Also, lifestyle issues can be addressed. Smoking is associated with a fivefold increased risk of postoperative complications [29, 30] and should be discouraged if possible for at least 8 weeks prior to surgery [30]. Similarly, alcohol abuse ([60 g ethanol per day) increases complication rates two- to threefold (most notably wound infections, bleeding, and cardiopulmonary insufficiency). In a randomized trial regarding colorectal surgery, abstinence for 1 month improved outcomes in alcohol misusers [31, 32]. Interestingly, several studies have shown the benefits of b-blockers and a2-agonists in blunting the overall systemic stress response, which may improve perioperative hemodynamic stability and surgical outcome (including reduced paralytic ileus and postoperative nausea and vomiting rates) [23, 33– 35]. The concept of commencing these and other agents specifically perioperatively to minimize stress response is intriguing but not yet fully developed.

Perioperative components Minimally invasive surgery Since its widespread propagation during the 1990s [36], minimally invasive surgery has proved to be one of the key technical advancements for patients undergoing colorectal surgery owing to its reductions in wound size, undesirable inflammatory responses, and catabolism. Multiple studies have repeatedly shown the benefits of the laparoscopic approach in reducing overall hospital stay by 1–4 days, with earlier recovery of gastrointestinal and pulmonary function and less overall morbidity and postoperative pain [3, 7, 15, 23, 37–43]. Although certain studies may show

no significant differences in postoperative morbidity, mortality, or readmissions between open and laparoscopic groups in an ERAS program [44], a minimally invasive approach naturally complements (or potentially supplants) a fast-track program in lessening injury to the patient and reducing intraoperative evaporative losses, peritoneal desiccation, and hypothermia. Excessively long procedure times can, however, mitigate against these effects especially if associated with extreme tilt positioning. To synergize the advantages of laparoscopy and ERAS, operations should be scheduled for early in the day so that postoperative day (POD) 1 activities can be begun on the afternoon of the operation. Recently, a multicenter randomized clinical trial investigated optimal perioperative treatment in 427 patients undergoing segmental resection for colon cancer (i.e., laparoscopic or open surgery combined with fast-track or standard care). The fast-track/laparoscopy group (n = 106) had the shortest total hospital stay and morbidity, but there was no significant difference in quality of life measures or in-hospital costs between the groups (Lap/FT, Open/FT, Lap/Standard, or Open/Standard) [37]. The latest Cochrane review also failed to show any difference between laparoscopy and the open approach in the fast-track setting, although one should be cautioned regarding the poor quality of the study design of the four randomized control trials (the overall bias did favor the laparoscopic approach) [17]. Although only large studies can determine the exact benefit of the minimal invasive approach in the fast track setting, it is unclear how many will be performed as most modern departments have adopted laparoscopic approaches as their standard of care [23]. Fasting protocols Initially, patients were in fact encouraged to take oral fluids on the morning of their surgery with clear fluids (during the

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1920s tea and hot glucose water were given 3 h preoperatively). This practice then changed to fasting for a minimum of 5 h (or more simply, nothing by mouth from midnight before surgery) to minimize the risk of aspiration. The scientific rationale underlying this paradigm shift remains unclear [45]. Several studies have since demonstrated that lengthy fasting periods are unnecessary; in fact, allowing patients to ingest clear liquids up to 2–3 h before surgery can reduce morbidity during the postoperative period [33]. Maltby et al. [45] reported significantly reduced gastric volume after their patients were given 150 ml of water approximately 2.5 h prior to surgery when compared to controls. Interestingly, Miller et al. [46] compared patients who fasted overnight with others allowed a light breakfast 2–4 h prior to elective surgery and found no change in the volume or median pH of gastric aspirates. Recently, the perioperative use of specific nutritional substrates in supranormal doses have shown immune-modulatory, anti-inflammatory, anabolic, and tissue protective properties that positively contribute to the surgical outcome when compared to traditional nutritional regimens [47]. Preoperative consumption of carbohydraterich fluids, for example, decreases patient anxiety by releasing endogenous opioids, thereby decreasing intraoperative anesthetic requirements, increasing gastric emptying, and improving insulin resistance with an overall reduction in the endocrine catabolic response [2, 48, 49]. Perioperative use of enteral formulas enriched with arginine and omega-3 fatty acids may also reduce infectious surgical complications [47, 50, 51]. The use of prebiotics, probiotics, and symbiotics in patients undergoing gastrointestinal surgery could also benefit by stabilizing the composition of the gut microbiota. However, such results are still limited and conflicting, probably owing to poor and variable study designs [47]. Fluid management Patients undergoing major colorectal surgery often receive liberal quantities of intravenous fluids perioperatively especially if epidural anesthesia is used [23]. Such fluid regimens supposedly maintain adequate tissue perfusion and oxygen delivery, and they overcome the osmotic effects of preoperative bowel preparation and lengthy fasting times [49]. However an average 3- to 6-kg increase in total body weight results along with delayed recovery of gastrointestinal function (gastric emptying time, time to first flatus, passage of stool) and decreased intestinal anastomotic burst pressure (owing to low muscular oxygen tension), increasing the hospital stay and surgical-site infection rates [52–56]. Fluid retention exceeding 67 ml/ kg/day within the initial 36 h postoperatively increases the risk of pulmonary edema and overall morbidity [57].

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Several studies have investigated the use of restrictive fluid regimens. Brandstrup et al. performed a randomized assessor-blinded multicenter trial comparing colorectal surgery patients on a restricted versus standard perioperative intravenous fluid regimen. The restricted group had significantly decreased cardiopulmonary and tissue healing complications and a trend toward reduced mortality [55]. Similar results were shown by Nisanevich et al. [59] and Khoo et al. [14]. Conversely, Holte et al. [60] found no difference in overall physiologic recovery in their liberal versus restrictive fluid allowance groups. Although there is no consensus regarding the ideal perioperative fluid regimen for patients undergoing colorectal surgery, the modern move away from routine antegrade mechanical bowel preparation and prolonged perioperative fasting, as well as the incorporation of closed-cavitary operative approaches such as laparoscopy, emphasizes the importance of evolving practice. Several studies have investigated the use of esophageal Doppler monitoring to tailor fluid requirement during surgery. This ‘‘goal-directed fluid therapy’’ (GDFT) aims to optimize the patients intravascular volume and tissue perfusion based on continuous cardiac output readings from an esophageal probe. The probe is inserted orally to lie above the cardia and is orientated to measure mainstream flow velocity in the descending thoracic aorta [61]. This relatively less invasive method of monitoring hemodynamic status has been shown to be superior to conventional parameters of tissue perfusion such as arterial blood pressure, central venous pressure, heart rate, and urine output [62]. Currently, three meta-analyses have examined the data from four large randomized control trials regarding this technology in colorectal/major abdominal surgery in a total of 393 patients [49, 62–64]. Overall, GDFT has shown to have a beneficial impact on almost every aspect of the surgical experience, being associated with decreased complications, intensive care unit (ICU) admissions, and inotropic need and with faster recovery of gastrointestinal function and shorter length of hospital stay. Such strong evidence has prompted some government-run health care authorities in Europe and the United States to advocate (and fund) routine esophageal Doppler usage for all colorectal surgery [49, 61, 65–67], a move echoed by the European Enhanced Recovery After Surgery Group [68]. Recent technologic advances may also improve circulatory flow assessment postoperatively, extending the principles of rational fluid supplementation after surgery. Pearse et al. [69], for example, performed a randomized controlled trial investigating postoperative GDFT in high-risk patients undergoing major general surgery. Their intervention arm (n = 62) had significantly fewer complications and shortened hospital stay, as was the case in two other similar cardiothoracic studies [70, 71].

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Regional and local anesthesia

stay in fluid-optimized patients given spinal anesthesia or PCA compared to those having an epidural procedure. This suggests that either of the former two modalities should supplant epidural analgesia usage [80].

Traditionally, postoperative pain has been controlled using enteral and parenteral medications [72, 73]. In addition to providing near-total afferent neural blockade, epidural anesthesia attenuates the overall endocrine catabolic stress response associated with surgery (e.g., the rise in cortisol, catecholamines, glucagon; hyperglycemia; insulin resistance; negative nitrogen balance) [74–77] and reduces the need for opiate analgesia [1]. Furthermore, and unlike epidural opioid or lumbar local anesthesia, continuous thoracic epidural analgesia with local anesthetics for up to 24–48 h may reduce postoperative ileus, thus playing an important role in initial colorectal fast-track protocols [1, 2]. A meta-analysis of randomized controlled trials investigating the comparative effects of postoperative analgesic therapies on pulmonary outcome showed the use of continuous epidural local anesthesia techniques was associated with a marked reduction in pulmonary complications when compared to that seen with intercostal block or epidural and systemic opioid techniques [77]. However, epidural anesthesia mitigates against early mobilization and is associated with systemic hypotension due to peripheral vasodilation that may require significant fluid bolus administration. The reduction in wound size and abdominal wall injury and the reduced tendency toward ileus in patients undergoing laparoscopic surgery has encouraged many to forego epidural techniques in favor of spinal analgesia (only useful for providing moderate analgesia) either alone or in combination with a more focused regional pain blockade, such as transversus abdominus preperitoneal plane (TAP) or rectus sheath blocks, or infusion catheters in combination (the latter are particularly applicable to single-incision laparoscopic procedures) with regular nonopioid analgesia. A nonrandomized comparative study has shown that patients who received TAP/patientcontrolled analgesia (PCA) had a significant reduction in overall intravenous opiate requirement with a trend to a shorter hospital stay [78]. Similarly, Zafar et al. [79] showed that patients who underwent laparoscopic colectomy and who underwent TAP/intravenous paracetamol had an accelerated recovery versus those receiving PCA. A recent Cochrane review, despite detailing benefits during the first 24 postoperative hours, was however inclusive regarding the use of TAP and rectus sheath blocks owing to heterogeneity in study protocols. Furthermore, there was no significant difference noted in the incidence of postoperative nausea and vomiting with the use of TAP blocks perhaps again due to intertrial variation. Currently, several studies are underway that are comparing TAP or rectus sheath blocks to epidural procedures, ilioinguinal nerve blocks, and wound infiltration [72]. One randomized control trial has recently reported reduced ileus and shorter hospital

Discussion The successful evolution of colorectal surgery is dependent on minimizing its impact on the patient. Fast-track rehabilitation programs utilize multimodal strategies to optimize conditions for surgery and recovery, thereby facilitating not only early discharge from the hospital and faster recovery regarding activities of daily living and work but also a happier in-hospital experience and more rapid and consistent progress to adjuvant postoperative therapies where required. Despite the large body of evidence available, however, adoption of the fast-track methodology has been disappointingly slow and inconsistent in both Europe and the United States [81], with proposed barriers being a lack of awareness, familiarity, agreement, self-efficacy, and outcome expectancy as well as the inertia of previous practice [82]. Perhaps much like laparoscopy itself, the advantages of enhanced recovery programs extend beyond simple hospital stay parameters, and many of the most important (e.g., staff engagement and morale) prove elusive to documentation in clinical studies of short duration. The ERAS platform also encourages the infrastructural development necessary to allow same-day or morning-ofsurgery admissions. This reduces the medical, anesthesia, and nursing staff workload around the time of admission and should make for calmer progression of the patient to the operating theater. The homogenization of care pathways across different consultant teams also allows increased confidence of care by medical and allied staff and consistency of comparative outcome and audit analysis. It also establishes a stable ground zero for research and innovation endeavors. Furthermore, the reduction in postoperative complications may significantly improve patients’ long-term outcomes that are not easily detectable in short-term analysis [83]. Although fast-track programs can do nothing to prevent the development of ‘‘surgical’’ or technical complications such as anastomotic leak or major postoperative hemorrhage, they do seem to predispose to their earlier detection. The obviation of ‘‘minor’’ nonsurgical complications allows improved ease and clarity of clinical examination; and industrialization of the processes should allow the patient suffering a complication to be identified readily by failure to reach the defined milestones. Put simply, nonprogression to expectation should indicate an early scan or even reoperation. Therefore, although the specific components of enhanced recovery can be criticized on the basis of a lack

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of absolutely compelling proof of benefit, there should be no doubt to any modern surgeon (especially current and next-generation laparoscopy surgeons) regarding its beneficial principles. The next phase of evolutionary development in the practice of colorectal surgery need not be continually focusing on picking apart the various individual aspects but use of the data and experience already established as a springboard into the next stage of operative practice and care. There is, of course, no specific recipe for immediate implementation, but each department interested in the care of its patients should carefully cater to the specific strengths and needs of its patients in setting in train the processes to ensure progressive quality of outcome.

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