Fast-Track Colonic Surgery: Status and Perspectives

Fast-Track Colonic Surgery: Status and Perspectives Henrik Kehlet H. Kehlet ( ) Section for Surgical Pathophysiology, Rigshospitalet, Section 4074, Blegdamsvej 9, 2100 Copenhagen, Denmark e-mail: henrik.kehlet@rh.dk Abstract Multi-modal rehabilitation with an emphasis on preoperative information, reduction of surgical stress responses, optimized dynamic pain relief with continuous epidural analgesia and early mobilization and oral nutrition may reduce hospital stay, morbidity, convalescence, and costs (fast-track surgery). Current results from fast-track colonic surgery suggest that postoperative pulmonary, cardiovascular, and muscle function are improved and body composition preserved as well as a normal oral intake of energy and protein can be achieved. Consequently, hospital stay is reduced to about 2 4 days, with decreased fatigue and need for sleep in the convalescence period. Despite a higher risk for readmissions, overall costs and morbidity seem to be reduced. Existing data from several institutions support the concept of fast-track colonic surgery to improve postoperative organ functions, thereby allowing for early rehabilitation with decreased hospital stay, convalescence, and costs. Further data are needed from multi-national institutions on morbidity, safety, and costs. Introduction In the last few decades, several improvements in perioperative care have been developed including newer anesthetic and analgesic techniques to provide early recovery and efficient pain relief [1] and new minimally invasive surgical techniques and pharmacological measures to reduce surgical stress [1, 2]. When these techniques have been combined with an adjustment of the overall perioperative program with regard to use of nasogastric tubes, drains, urinary catheters, and early institution of oral feeding and mobilization, major improvements have been achieved in a variety of surgical procedures [1, 2]. Colonic surgery has usually been associated with a complication rate of 15% 20% and a postoperative hospital stay of 6 10 days, the limiting factors for early recovery and discharge being pain, recovery of gastrointestinal function to allow Recent Results in Cancer Research, Vol. 165 c Springer-Verlag Berlin Heidelberg 2005

Fast-Track Colonic Surgery: Status and Perspectives 9 normal food intake, fatigue, and other organ dysfunctions. In recent years, several efforts have been made to standardize perioperative care protocols after colonic surgery [1 4] in order to achieve earlier restoration of body organ functions, in the hope that need for hospitalization and morbidity subsequently would be reduced. This paper is a short update on the current status of such multimodal rehabilitation programs in elective colonic procedures. Results The results are summarized in Table 1. In all available reports on fast-track colonic surgery, a revised perioperative care program has been instituted with avoidance of nasogastric tubes, early institution of oral feeding and mobilization, optimized multimodal analgesia (most often including continuous epidural analgesia) and a pre-planned program for early discharge. Table 1. Effects of fast-track colonic surgery on organ functions, hospital stay, convalescence, and costs References Ileus [3, 7, 8, 9, 10, 12, 14, 16, 17, 18, 19] Pulmonary function and oxygen saturation [7] Exercise capacity [7, 8] Muscle strength [9, 10] Body composition (lean body mass) [7, 11] Oral energy and protein intake [11] Cardiopulmonary morbidity [12] Hospital stay [3, 7, 10, 12, 14, 15, 16, 17, 18, 19, 20, 21] Readmissions ( ) [10, 12, 14, 15, 19] Postoperative fatigue and need for sleep [10, 13] Costs [14] Ileus Due to the avoidance of nasogastric tubes with early institution of oral intake facilitated by continuous epidural local anesthetic techniques [5, 6], the duration ofileushasbeenreducedfromusually4 5daystoabout2days(Table1).This is a significant benefit, since discomfort due to abdominal distension is avoided and since early institution of oral nutrition can be instituted, which otherwise has been demonstrated to reduce catabolism and morbidity [1, 2].

10 Henrik Kehlet Pulmonary Function and Oxygen Saturation Early institution of mobilization facilitated by optimized pain relief with epidural analgesia has been demonstrated in comparative, nonrandomized studies [7] to improve pulmonary function and oxygen saturation, especially during night time (Table 1). Exercise Capacity Fast-track colonic surgery programs have been shown in comparative, nonrandomized studies to improve exercise capacity since the usual approximately 40% deterioration of exercise performance could be avoided [7, 8] (Table 1). Muscle Strength In two randomized studies, muscle strength assessed by the force of the quadriceps muscle [9] or handgrip strength [10] was improved by fast-track compared to conventional care colonic surgery (Table 1). Body Composition In comparative studies with conventional care, fast-track colonic surgery led to preservation of body composition (lean body mass) as assessed from before to 7 8 days postoperatively [7, 11] (Table 1). Oral Energy and Protein Intake An about 40% 50% increase in oral energy and protein intake could be achieved with a fast-track program [11] which may account for the preservation of lean body mass (Table 1). Cardiopulmonary Morbidity In a large, comparative, nonrandomized study, a multimodal rehabilitation program decreased cardiopulmonary morbidity compared to conservative treatment [12] (Table 1). These findings may correspond to improved organ functions with less reduced pulmonary function and improved oxygen saturation [7].

Fast-Track Colonic Surgery: Status and Perspectives 11 Hospital Stay In all available studies (Table 1), hospital stay was significantly reduced from about 6 10 days to 2 4 days (Table 1). However, in three of these studies, the aim was to restore organ functions, while no aim was made specifically on early discharge [8, 9, 11]. It is important to mention that discharge criteria were unchanged during fasttrack programs and the reduced hospital stay is therefore due to earlier achievement of discharge criteria (sufficient pain relief with oral analgesics, normalization of gastrointestinal function allowing normal oral intake, and patient acceptance). Readmissions In some, but not all series, an increased rate of admission was observed, but no safety problems were demonstrated, especially in the few patients who had an anastomotic dehiscence diagnosed after discharge (Table 1). Obviously, further data on readmissions and safety aspects are required in large series before final conclusions can be drawn. Postoperative Fatigue and Convalescence In the few comparative studies, postoperative fatigue was reduced [10, 13], even in the weeks after discharge, and the need for sleep was also reduced after fast-track care. At the same time, there was no increased need for health care support after discharge with fast-track programs and no increased need for visits to general practitioners (Table 1). Costs In the few studies available [14], the early restitution of body organ functions allowing for early discharge and increased convalescence with a potential reduction in morbidity also led to significant cost reductions (Table 1). Discussion and Conclusions From the available data on fast-track colonic surgery including a few randomized [9, 10, 11, 15] studies it appears that a revision of the perioperative care program including optimized pain relief with continuous epidural analgesic techniques [6] and enforced early oral nutrition, postoperative mobilization, and comprehensive preoperative information together with a well-defined postoperative nursing care program and discharge plan has led to significant improvements in outcome by reducing organ dysfunctions, cardiopulmonary morbidity, duration of ileus, and subsequently hospital stay. Furthermore, these findings include a potential for

12 Henrik Kehlet improved convalescence with less fatigue and need for sleep, without increased need for health care support and visits to general practitioners. Additional factors with potential importance for a successful fast-track program include avoidance of perioperative fluid excess [22, 23], which otherwise may increase postoperative morbidity [23]. Although continuous epidural analgesia has been demonstrated to provide benefits after abdominal procedures by improving pain relief [6], reduction of ileus, and postoperative catabolism [5, 6], a few studies with successful fast-track colonic surgery did not use epidural analgesia [15, 19, 20]. Further studies are therefore needed to define the exact role of continuous epidural analgesia. Also, several fast-track programs utilized laparoscopic-assisted colonic resection, but nearly the same results were achieved with a combination of conventional open procedure compared with a fast-track care program [12, 16, 17, 20, 21], although lower costs were claimed with the laparoscopic approach [21, 24]. Further randomized studies are required to compare open versus laparoscopicassisted colonic surgery in a fast-track program before final conclusions can be made about the potential additional benefits of performing the operation with laparoscopic assisted. In conclusion, existing data on fast-track colonic surgery are all based on evidence from the single components of perioperative care (preoperative information, short-acting general anesthetics, epidural analgesia, early oral nutrition, enforced mobilization, avoidance of fluid excess, and avoidance of nasogastric tubes and drains) [1, 2] and have subsequently confirmed that conventional discharge criteria can be achieved earlier with subsequently reduced hospital stay. The data also suggest that postoperative medical morbidity can be reduced without an increased risk of surgical (wound and anastomotic) morbidity. These promising data should be extended to other centers in several countries in order to establish safety aspects and cost issues. The results achieved to date with fast-track colonic surgery seem to have major implications for improving care of these often high-risk patients, and the results also serve as a stimulus for development of fast-track programs in other high-risk surgical populations [1, 2]. Acknowledgements. Supported by a grant from Apoteker Fonden af 1991. References 1. Kehlet H, Dahl JB (2003) Anaesthesia, surgery and challenges for postoperative recovery. Lancet 362:1921 1928 2. Kehlet H, Wilmore DW (2002) Multi-modal strategies to improve surgical outcome. Am J Surg 183:630 641 3. Basse L, Jakobsen DH, Billesbølle P, Werner M, Kehlet H (2000) A clinical pathway to accelerate recovery after colonic resection. Ann Surg 232:51 57 4. Wexner S (1998) Standard perioperative care protocols and reduced length of stay after colon surgery. Am J Coll Surg 186:589 593 5. Holte K, Kehlet H (2002) Epidural anaesthesia and analgesia effects on surgical stress responses and implications for postoperative nutrition. Clin Nutr 21:199 206 6. Jørgensen H, Wetterslev J, Mønniche S, Dahl JB (2001) Epidural local anaesthetics vs opioid based analgesic regiments on postoperative gastrointestinal paralysis, PONV and pain after abdominal surgery (Cochrane review). Cochrane Library, issue 2,. Oxford: Update Software

Fast-Track Colonic Surgery: Status and Perspectives 13 7. Basse L, Raskov H, Jakobsen DH, Sonne E, Billesbølle E, Hendel HW, Rosenberg J, Kehlet H (2002) Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg :89:446 453 8. Carli F, Mayo N, Clubien K, Schricker T, Trudel J, Bellivau P (2002) Epidural analgesia enhances exercise capacity and health related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 97:540 549 9. Henriksen MG, Jensen MB, Hansen HV, Jespersen TW, Hessov I (2002) Enforced mobilization, early oral feeding, and balanced analgesia improve convalescence after colorectal surgery. Nutrition18:147 152 10. Anderson, ADG, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90:1497 1504 11. Henriksen MG, Hansen HV, Hessov I (2002) Early oral nutrition after elective colorectal surgery: influence of balanced analgesia and enforced mobilization. Nutrition 18:266 269 12. Basse L, Thorbøl JE, Løssl K, Kehlet H (2004) Convalescence after fast-track versus conventional care of colonic surgery. Dis Colon Rectum 47:271 278 13. Hjort Jakobsen D, Sonne E, Basse L, Bisgaard T, Kehlet H (2004) Convalescence after colonic resection with fast-track vs. conventional care. Scand J Surg (in press) 14. Stephen AE, Berger DL (2003) Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical pathway after elective colonic resection. Surgery 133:277 282 15. Delaney CP, Zutshi M, Senagore AJ, Remzi FH, Hammel J, Fazio VW (2003) 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 46:851 859 16. Senagore AJ, Duepree HJ, Delaney CP, Brady KM, Fazio VW (2003) Results of a standardized technique and postoperative care plan for laparoscopic sigmoid colectomy. A 30-month experience. Dis Colon Rectum 46:503 509 17. Bardram L, Funch-Jensen P, Kehlet H (2000) Rapid rehabilitation in elderly patients after laparoscopic resection. Br J Surg 87:45 45 18. Basse L, Jacobsen DH. Billesbølle P, Kehlet H (2002) Colostomy closure after Hartman s procedure with fast-track rehabilitation. Dis Colon Rectum 45:1661 1664 19. DiFronzo, Yamin N, Patel K, O Connell TX (2003) Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg 197:747 753 20. Delaney CP, Fazio VW, Senagore AJ, Robinsson B, Halvorson AL, Remzi FH (2001) Fasttrack postoperative management protocol for patients with high co-morbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 88:1533 1538 21. Senagore AJ, Duepree HJ, Delaney CP, Dissanaike S, Brady KM, Fazio VW (2002) Cost structure of laparoscopic and open sigmoid colectomy for diverticular disease. Similarities and differences. Dis Colon Rectum 45:485 490 22. Holte K, Sharrock NE, Kehlet H (2002) Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 89:622 632 23. Brandstrup B, Tønnesen H, Beier-Holgersen R, Hjortsø E, Ørding H, Lindorff-Larsen K, Rasmussen MS, Lanng C, Wallin L and the Danish study group on perioperative fluid therapy (2003) Effects of intravenous fluid restriction on postoperative complications: Comparison of two perioperative fluid regimens. Ann Surg 238:641 648 24. Delaney CP, Kiran RP, Senagore AJ, Brady K, Fazio VW (2003) Case-matched comparison of clinical and financial outcome after laparoscopic and/or open colorectal surgery. Ann Surg 238:67 72