M. Kremer, A. Ulrich, M. W. Büchler, W. Uhl
W. Uhl ( u)
Department of Surgery, St. Josef-Hospital Bochum, Ruhr-University, Gudrunstr. 56, 44791 Bochum, Germany
e-mail: w.uhl@klinikum-bochum.de
Abstract
Fast-track surgery is an interdisciplinary multimodal concept of minimally inva- sive surgery or new incision lines and “cutting old plaits” (e.g., the use of drains or tubes). It uses modern intraoperative anesthesia (e.g., fluid restriction) and analgesia, including new drugs and novel ways of administration (e.g., thoracic epidural analgesia) for postoperative pain relief, in combination with the im- mediate mobilization of the patient and early oral nutrition after the operation.
This approach requires a cooperating team of motivated nurses, physiotherapists, anesthesiologists, and surgeons, in addition to continuous improvement of the processes involved. Moreover, extended patient education and information about the procedures and the expected time course are of the highest importance, as the active role of the patient is to be emphasized. This chapter describes the de- velopment and implementation of fast-track surgery in colorectal diseases at the Department of Surgery of the University Hospital of Heidelberg, Germany. Pre- liminary results of fast-track surgery suggest a significant and clear overall benefit for the patient. A shorter hospital stay and reduced systemic morbidity in addition to no increase in postoperative complications on an out-patient basis were found.
However, to exclude a “bloody discharge” of the patients, thorough follow-up and quality control are mandatory. Although in the initial phase increased personnel care is necessary, in the new German reimbursement system with G-DRGs (Ger- man diagnosis-related groups) fast-track surgery seems to save resources in the long term.
Development of Fast-Track Surgery
Over the past decade, advances in healthcare with an evolution in peri- and post- operative care have led to a new surgical approach, the so-called fast-track surgery.
Improved understanding of postoperative physiology in particular has led to re- Recent Results in Cancer Research, Vol. 165
Springer-Verlag Berlin Heidelberg 2005 c
ductions in the length of time spent in the hospital after surgery [1, 2], thus saving resources.
In fast-track surgery, a multimodal pathway is applied to patients. In addition to minimally invasive procedures and laparoscopic surgery [3, 4], postoperative stress was reduced to a minimum. Surgeons and anesthesiologists have been using epidural regional anesthetic agents to reduce the stress response associated with elective surgery [5]. An advantage has also been obtained with the use of new pharmacologic agents that control nausea, vomiting, gastric ileus and infection, thereby dramatically reducing the incidence of postoperative complications [6–9].
Such a multimodal approach seems to shorten surgical convalescence follow- ing major operative procedures, with dramatically reduced medical morbidity, whereas surgical morbidity is not affected [10, 11].
The Heidelberger Concept
Key factors of fast-track surgery involve thorough patient education, a multidisci- plinary team approach to surgical management, epidural anesthetic administra- tion, and early nutrition and ambulation after the procedure.
In accord with the findings and experience of Delaney et al. [11] and Kehlet et al. [12], we developed a modified fast-track surgery concept, which applies to specific clinic-associated routines.
Most important in using fast-track procedures is to gain the cooperation of the patient. Therefore intensive education of the patient preoperatively including writ- ten guidelines that describe the future hospital stay, surgical and anesthesiological procedures, milestones of personal recovery, and a set of discharge instructions is given to the patient before the operation. The active role of the patient, guided by a team of specialists, is outlined in Fig. 1.
The trend toward fast-tracking is challenging a number of surgical traditions, including routine use of preoperative bowel preparation and nasogastric tube
The active role of the patient
Patient
Nurses
Physiotherapist Doctors
Information pre-/
postoperative management
Surgical and anaesthesiological approach
Physician Mobilisation
Food intake
Figure 1. Underlining the importance of active cooperation of the patient with surgeons, anesthesists, nurses,
and physiotherapists. Cooperation is achieved by extended preoperative education, minimally invasive surgery
and anesthesiology, early mobilization, and early postoperative food intake
decompression. According to the newest findings in evidence-based medicine, preoperative bowel preparation has no advantage. In a review with a total of 1,204 patients, no bowel preparation did not adversely affect mortality, re-operation rate, or wound infection. Furthermore, the rate of anastomotic leakage seemed to be reduced [13].
Similar results were found for the use of nasogastric tubes. The first prospective and randomized study in 1993 showed that nasogastric decompression is not necessary following elective colorectal surgery [14]. However, it was nearly a decade until other studies supporting these findings were published [15, 16], leading now to a reduced use of nasogastric tubes. A meta-analysis of nearly 4,000 patients even demonstrated, surprisingly, that routine use of nasogastric tubes after laparotomy increased the incidence of complications, such as pneumonia and atelectasis, and decreased the time to oral feeding [17].
Therefore the use of nasogastric tubes in our model of fast-track surgery is mostly limited to the day of operation. The tubes are removed within hours after the operation, if there is a reflux of less than 200 ml.
Epidural anesthesia is a key factor, because it blocks the painful stimulus that interferes with postoperative bowel function and contributes to ileus and other potential complications due to immobilization. A review comparing the use of spinal or epidural anesthesia with or without additional general anesthesia and general anesthesia alone demonstrated a significant reduction in postoperative mortality and in the rate of systemic morbidity such as pneumonia, myocardial infarction, bleeding, and transfusion requirements [18].
The combination of therapeutic modalities in fast-track surgery is helpful in overcoming intraoperative factors that tend to delay recuperation. These include blood transfusions which suppress the immune system, and hypothermia, which has been shown to increase the length of hospitalization, particularly for elderly patients [19]. The routine use of drains in several abdominal operations does not improve outcome, as determined by randomized clinical studies [20, 21]. Therefore we perform routine fast-track operations without drains.
Extubation in the OR, early mobilization 6 h after surgery, and drinking of small amounts of noncarbonated liquids 6 h after surgery are implemented in favor of fast recovery.
The first day after the operation, patients receive a protein drink to improve bowel movement; noncarbonated liquids are ad libitum, and soft diet is allowed in the evening. Extended mobilization of at least 50m on the ward is supported by physiotherapists, as are regular respiratory exercizes. The postoperative urinary bladder drainage is removed analogue to the achieved state of mobilization on post- operative day (POD) 1 or 2, according to the findings of controlled trials [22, 23].
As outlined in Table1, on POD 2, the epidural catheter is removed and non-opioid oral analgesia is started. Mobilization and respiratory exercizes are extended, and in the evening the patients get solid food.
On POD 3–5, patients are discharged with instructions to visit their physician
the next day and our outpatient clinic one week later. The patients are advised to
come to our outpatient clinic immediately if they experience any problems.
Table 1. Scheme of the Heidelberg concept of fast-track surgery (POD, postoperative day)
On the day of operation:
No preoperative bowel preparation
Nasogastric tube only during anesthesia, removed the same day Thoraic epidural analgesia
Extubation in operating theatre
Start with small amounts of noncarbonated liquids 6 h after surgery Early mobilization 5 h after surgery
POD 1
Protein drinks/laxative
Early mobilization: walking about 50 m in the ward Regular respiratory exercise
Liquids ad libitum Soft diet in the evening
POD 2
Removal of epidural catheter, start with non-opioid oral analgesia Extended mobilization and regular respiratory exercise
Liquids ad libitum Solid food
POD 3 till discharge Oral analgesia
Further extended mobilization Liquids ad libitum
Solid food
Preliminary Results
To establish the fast-track surgery concept in Heidelberg, the multimodal concept had to be introduced to different disciplines, including nursing and physiotherapist staff. It took nearly one year to implement the modalities of fast-track surgery. From September to November 2003, 26 patients were included in the study.
Based on preliminary results, our concept of fast-track surgery is feasible, ensur-
ing a shorter stay and less systemic morbidity. Patients appeared to have less pain
and returned to normal physical activities in a much shorter time than patients
managed with traditional techniques.
An important question concerning the early discharge in fast-track surgery is the safety of the patient during the development of abdominal problems in cases of anastomotic leakage. Included in the education of the patient is extensive information about calling our outpatient clinic as well as coming in at any time to our clinic, if any adverse symptoms or signs of complications occur. To date, our patients have suffered no anastomotic leakage, and no adverse effects have been reported when patients were instructed to call the physician if they develop suspicious symptoms at home [24].
Whereas the majority of publications describe the impact of minimally invasive surgery such as laparoscopy-assisted techniques [4, 25] with fast-track surgery, Basse et al. [24] achieved the same results with open colonic resection, suggesting that postoperative recovery may depend more on other factors such as optimal pain relief, early nutrition, and early mobilization and omission of recovery-inhibiting regimens than on the choice of surgical technique itself. These findings concur with our preliminary observations. Therefore minimally invasive surgery must also be questioned if fast-track open surgery can achieve a similar postoperative length of stay.
More studies of the fast-track surgical approach are needed. As it is impossible to randomize and blind patients, nurses, and doctors in a project with multimodal rehabilitation, large multicenter comparative studies must be initiated to evaluate the benefits of the approach of fast-track surgery.
Reimbursement: German DRG (Diagnosis-Related Groups)
Worldwide health care systems are changing significantly, mainly due to limited financial resources. For the reimbursement of hospitalized patients, the diagnosis- related groups that originated in the USA and improved in Australia have been adopted in Germany since 2004. Table 2 gives the data of patients undergoing rectal and colonic/sigmoidal resections with regard to the allowed hospital stay,
Table 2. Reimbursement according to the German diagnosis-related groups (G-DRG). Shown are data of rectal and colonic/sigmoidal resections with regard to the allowed hospital stay, cost weight and earnings with co-morbidity/complications (A) or without (B). Minimal hospital stay varies between 4 and 6 days, whereas the maximum stay is between 28 and 39 days
G-DRG Hospital stay Cost weight Earnings
aRectal resection
G01A 22.2 (6–39 days) 4.009 12.107 euro
G01B 17.4 (5–30 days) 2.915 8.803 euro
Colonic/sigma resection
G02A 21.4 (6–39 days) 3.532 10.667 euro
G02B 15.9 (4–28 days) 2.414 7.290 euro
a
