Convalescence after colonic surgery with fast-track vs conventional care

OBJECTIVE: To compare convalescence after colonic surgery with a fast-track rehabilitation programme vs conventional care. BACKGROUND: Introduction of a multimodal rehabilitation programme (fast-track) with focus on epidural anaesthesia, minimal invasive surgical techniques, optimal pain control, and early nutrition and mobilization together with detailed patient information have led to a shorter hospital stay after colonic surgery. There are not much data on convalescence after discharge. METHODS: A prospective, controlled, non-randomized interview-based assessment in 160 patients undergoing an elective, uncomplicated, open colonic resection or the Hartmann reversal procedure with a fast-track or a conventional care programme in two university hospitals. A structured interview-based assessment was performed preoperatively, and day 14 and 30 postoperatively. RESULTS: Patients undergoing colonic surgery with a fast-track programme regained functional capabilities earlier with less fatigue and need for sleep compared with patients having conventional care. Despite early discharge of the fast-track patients (mean 3.4 days vs 7.5 days), no differences were found according to the need for home care, social care and visit to general practitioners, although the fast-track group had an increased number of visits at the outpatient clinic for wound care. More patients in the fast-track group were re-admitted, but the overall mean total hospital stay was 4.2 days vs 8.3 days in the conventional group. CONCLUSION: A fast-track rehabillitation programme led to a shorter hospital stay, less fatigue and earlier resumption of normal activities, without the increased need for support after discharge compared with conventionally treated patients after uncomplicated colonic resection.     

Laparoscopic colonic resection in fast-track patients does not enhance short-term recovery after elective surgery

BACKGROUND: Laparoscopic colorectal surgery has been claimed to enhance recovery when compared with open surgery. The aim of our study was to investigate whether laparoscopic colorectal resection improved recovery with the use of a multimodal rehabilitation programme. METHOD: We carried out a prospective audit of 80 patients undergoing elective colorectal resection between November 2003 and March 2005. All patients underwent a fast-track protocol with early feeding, mobilization and a fluid and sodium restriction regime. Recovery was measured in terms of return of gastrointestinal function, hospital stay, complications and quality of life measures. RESULTS: Of the 80 patients in the study 22 underwent laparoscopic resection and 58 had open surgery. Patients were well matched for all baseline characteristics. The groups were not significantly different in terms of opioid or antiemetic use. They were also similar in median time to first flatus (69 h vs 69 h, P = 0.36) and median time to first bowel motion (127 h vs 101 h, P = 0.07). There was no difference in median hospital stay (5.8 days vs 5.9 days, P = 0.87) or complications (P = 0.46) between the laparoscopic and open group. There were no significant differences in Short Form 36 scores between the two groups for any of the components measured. CONCLUSION: Laparoscopic colorectal resection does not appear to reduce the duration of ileus or hospital stay with the use of a multimodal rehabilitation regime. Further large randomized trials are required to confirm these findings.     

Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study

Background: Evidence-based guidelines on optimal perioperative fluid managementhave not been established, and recent randomized trials in majorabdominal surgery suggest that large amounts of fluid may increasemorbidity and hospital stay. However, no information is availableon detailed functional outcomes or with fast-track surgery.Therefore, we investigated the effects of two regimens of intraoperativefluids with physiological recovery as the primary outcome measureafter fast-track colonic surgery. Methods: In a double-blind study, 32 ASA I–III patients undergoingelective colonic surgery were randomized to ‘restrictive’(Group 1) or ‘liberal’ (Group 2) perioperative fluidadministration. Fluid algorithms were based on fixed rates ofcrystalloid infusions and a standardized volume of colloid.Pulmonary function (spirometry) was the primary outcome measure,with secondary outcomes of exercise capacity (submaximal exercisetest), orthostatic tolerance, cardiovascular hormonal responses,postoperative ileus (transit of radio-opaque markers), postoperativenocturnal hypoxaemia, and overall recovery within a well-definedmultimodal, fast-track recovery programme. Hospital stay andcomplications were also noted. Results: ‘Restrictive’ (median 1640 ml, range 935–2250ml) compared with ‘liberal’ fluid administration(median 5050 ml, range 3563–8050 ml) led to significantimprovement in pulmonary function and postoperative hypoxaemia.In contrast, we found significantly reduced concentrations ofcardiovascularly active hormones (renin, aldosterone, and angiotensinII) in Group 2. The number of patients with complications wasnot significantly different between the groups (1 vs 6 patients,P = 0.08). Conclusions: A ‘liberal’ fluid regimen led to a transient improvementin pulmonary function and postoperative hypoxaemia but no otherdifferences in all-over physiological recovery compared witha ‘restrictive’ fluid regimen after fast-track colonicsurgery. Since morbidity tended to be increased with the ‘restrictive’fluid regimen, future studies should focus on the effect ofindividualized ‘goal-directed’ fluid administrationstrategies rather than fixed fluid amounts on postoperativeoutcome.     

快速康复外科新理念在结直肠手术中的应用

目的:研究快速康复外科(fast-track surgery,FTS)新理念在结直肠手术中应用的安全性和有效性.方法:将61例结直肠择期手术患者随机分为快速康复组(FTS组)和对照组,分别用FTS和传统方法处置,比较患者的应激和术后恢复指标.结果:与对照组相比,FTS组患者术后应激水平减轻,术后康复进程明显加快.结论:整合一系列围手术期干预措施的FTS可有效减轻患者应激,明显加速术后康复进程,在结直肠手术中的应用是安全可行的.     

Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery

BACKGROUND: Initial programmes of fast-track open colonic surgery with a planned 2-day postoperative hospital stay have had a high readmission rate (about 20 per cent). The aim of this large, consecutive series was to compare readmission rates after a fast-track open colonic surgery programme with a planned hospital stay of 2 versus 3 days. METHODS: The study included 541 consecutive colonic resections from one surgical department with a structured care programme, including well defined discharge criteria, between April 1997 and December 2005. The planned hospital stay was increased from 2 to 3 days from August 2004. All patients were examined 8 and 30 days after surgery. RESULTS: Readmission rates fell from 20.1 per cent in 408 patients with a planned 2-day hospital stay (period 1) to 11.3 per cent in 133 patients with a planned 3-day hospital stay (period 2) (P < 0.020). Median length of primary hospital stay was 2 and 3 days, median stay after readmission was 5 and 5.5 days, and median (mean) total stay was 3 (5.6) and 3 (5.7) days in periods 1 and 2 respectively. The readmission rate in period 2 was lower because there were fewer readmissions for short-term observation or social reasons. There was no difference in type and incidence of morbidity between the two periods. CONCLUSION: Readmission after fast-track open colonic resection was reduced by planning discharge 3 instead of 2 days after surgery, with the same discharge criteria.     

对Fast-track surgery内涵的认识

近年来,国际外科文献检索资料中,Fast-track surgery一词频繁出现,也有不少以此为题的文章,涉及到各个区域的手术,效果甚佳,明显加快了患者的康复,缩短了手术后住院时间.国内,外科学术会议也对此感兴趣,进行了讨论.Fast-track一词在英语中常用以描述事物能迅速完成的途径、方法,Fast-track surgery当指手术快速完成之意.     

Implementation of the scientific evidence into daily practice – example from fast-track colonic cancer surgery

Objective  To report the implementation and results of fast-track surgery for colonic cancer in the daily routine.
Method  A total of 131 consecutive patients scheduled for elective colonic cancer resections entered a fast-track perioperative course after thorough information. The regimen contained: no preoperative bowel cleansing, transverse and small abdominal incisions, no dains nor tubes, mobilization and normal meal the evening on the day of surgery, epidural analgesia, oral laxatives, and a planned discharge on postoperative day 3.
Results  Median number of days postoperative in hospital were 4 days (range 1–46). Eighty-nine per cent experienced an uncomplicated course, 3% were readmitted within 30 days, and the 30-day mortality was 3.8%.
Conclusion  Fast-track surgery is feasible in an unselected patient population scheduled for elective colon cancer resections without compromising quality.     

Delirium in vascular surgery.

Delirium is common in many surgical settings. Patients undergoing elective vascular surgery may be at particular risk of developing delirium, and may have modifiable aetiological factors that can be addressed by pre-operative interventions. We decided to review the literature regarding the incidence and aetiology of delirium in elective vascular surgical patients. METHODS: We searched medical databases, journals and bibliographies to identify relevant studies. We used predetermined quality criteria for appraisal of the quality of incidence and aetiological studies. RESULTS: Four studies were identified as relevant to the review. The incidence of delirium ranged from 29.1% to 39.2%. The significant aetiological factors identified were age, pre-operative cognitive impairment, depressive symptoms, inter-operative blood transfusion and previous amputation. CONCLUSIONS: Delirium is common in people undergoing elective vascular surgery. Further research is required to examine the effect on outcome of delirium, and the effect of psychiatric and geriatric medicine interventions in this setting.     

Delirium tremens in accident surgery

The case histories of 49 patients suffering from delirium tremens in a trauma hospital are described. Particular attention is devoted to two questions: 1. Is delirium tremens always coupled with a low serum K+? It was shown that a low serum K+ in this illness is frequent but not obligatory. 2. Is there a danger that a relapse could ensue by another operation carried out within a relatively short interval after delirium tremens? It was found that as a rule there is no relapse.     

快速康复外科在根治性全膀胱切除术中的应用

快速康复外科是由丹麦外科医师Kehlet提出,旨在通过减轻围术期的应激反应而促进患者术后康复,减少手术并发症.距快速康复外科理念提出已有近20余年,在这期间,快速康复外科理念在国外得到了极大地发展,并在普外科,尤其是结直肠外科、心胸外科、妇科等进行应用,取得了极大地成功,后被黎介寿院士引入我国,并迅速被外科医师所接受,尤其是在结直肠切除手术中的成功应用已成为典范,但在根治性全膀胱切除术中应用相对较少,本文就快速康复外科理念在根治性全膀胱切除术中的应用作一综述,以期能促进这一理念在该术式中的推广应用.     

加速康复外科的临床应用进展

随着外科技术和多种辅助治疗手段的不断进步,患者外科手术后的康复取得了一定成绩,但仍然存在诸多问题.而加速康复外科采用已证实有效的各种方法,如术前思想准备、术前肠管准备新观点、术中麻醉管理、微创外科的应用、液体管理及体温维持以及术后早期活动、早期进食对症治疗及镇痛的应用等,可以减少手术应激及常见并发症发生率,减少患者痛苦,加速患者术后康复,从而达到缩短住院日期的目的 .加速康复外科追求"以患者为中心",使患者在住院期间最大获益是加速康复外科治疗技术的最终目的 .     

Future perspectives and research initiatives in fast-track surgery

Background and aims Major surgery is still followed by a risk of morbidity, a need for hospitalisation and convalescence. Fast-track surgery has been introduced as a coordinated effort to combine unimodal evidence-based principles of care into a multi-modal effort to enhance recovery. The aim of this article was to update recent data on fast-track abdominal surgery and outline future strategies for research.Results The data from fast-track colonic resection support the validity of the concept because pain, ileus, cardiopulmonary function and muscle function were all improved, compared with traditional treatment and with reduced post-operative fatigue and convalescence. Although less data is available, similar positive results may be achieved in other types of major surgery. Current research initiatives include improved multi-modal non-opioid analgesia, rational principles for perioperative fluid management, pharmacological reduction of surgical stress responses and the role of laparoscopic procedures within the fast-track concept.Conclusions Fast-track surgery has evolved as a valid concept to improve post-operative outcome. Further progress may be expected based upon intensified research within perioperative pathophysiology and a multi-disciplinary collaboration between surgeons, anaesthesiologists and surgical nurses.     

加速康复外科在胰腺肿瘤围手术期中的应用

加速康复外科(fast-track surgery)强调在围手术期应用一系列各种已证实有效的措施,加以优化组合而产生协同效果,以最大限度缓解各种手术患者生理及心理应激反应.加速康复外科旨在提高医疗卫生工作效率,减少住院时间,降低住院费用,提高患者术后生活质量,其在结-直肠手术患者围手术期应用的安全性、有效性已得到广泛证实,而应用胰腺手术的报道较少.本文就加速康复外科在胰腺肿瘤的应用现状及与患者入院率、发病率、病死率的联系和临床意义加以综述.

Abstract：

Fast-track recovery emphasize applicating a series of effective measures confirmed in the perioperative care of patients,the optimized combination generates synergy effect to maximize alleviating various physical and mental stress reaction in order to expedite patient recovery.Most successful example is the application of fast track colon surgery program.Its safety and effectiveness have been widely confirmed,but the report on pancreas surgery is limited.FTRP is aiming to improve medical and health work efficiency,reduce hospitalization time and hospitalization expenses,improve life quality of patients.Based on the application of FTRP in pancreatic cancer,the relation of morbidity,re-admission and peri-operative mortality rates and clinical significance are reviewed.     

Use of cisatracurium during fast-track cardiac surgery

We prospectively studied spontaneous recovery from cisatracurium-inducedneuromuscular block in 18 patients scheduled for cardiac surgery,and its suitability for fast-track cardiac surgery. Neuromuscularblock was induced by an i.v. bolus (range 0.15–0.3 mgkg^–1) and maintained by a continuous infusion (range 1.1–3.2µg kg^–1 min^–1) of cisatracurium until sternalclosure. In the intensive care unit (ICU), spontaneous recoverywas evaluated by the train-of-four (TOF) ratio measured at theadductor pollicis muscle. The ICU medical staff were unawareof the TOF ratios until sedation was stopped. At that time,if the TOF ratio was less than 0.9, sedation was recommenced.On arrival in ICU, all patients had residual paralysis. Themean time to reaching a TOF ratio of at least 0.9 was 102 min(range 74–144 min) after discontinuation of the cisatracuriuminfusion. Fifteen patients (83%) were successfully extubatedduring the first 8 h after stopping the cisatracurium infusion.Only one patient showed residual paralysis when sedation wasdiscontinued. These results support the use of cisatracuriumas a suitable neuromuscular blocking agent for fast-track cardiacsurgery. Br J Anaesth 2001; 86: 130–2     

快速康复外科在胃癌外科的应用与展望

快速康复外科是利用新的医学证据为优化围手术期患者管理提供依据,外科医师通过整合和应用这些新证据形成一整套围手术期的管理方法,以达到减少患者生理及心理上的应激反应,加快患者的康复.快速康复外科已应用于多种外科疾病的治疗,包括心脏手术、全膝关节置换、结直肠手术等.胃癌是世界第四常见、病死率第二的恶性肿瘤.外科手术是胃癌治疗的里程碑,也是唯一的、有效的根治胃癌的手段.但快速康复外科在胃癌治疗中的应用还在不断完善.本文就快速康复外科在胃癌外科的应用进展进行综述.