FAST TRACK SURGERYEnhanced Recovery After Surgery

ERASBy

Mohamed El-sayed AbosdiraResident Doctor at general surgery department

Sohag university hospital

WHAT is Fast Track Surgery ??

Dogma: Back to the Past….Senior surgeons had strong principles and they were assumed as a dogma.• Preoperative prolonged fasting, Mechanical bowel

preparation and nasogastric tubes were thought to be necessary to

empty the bowel to prevent intraoperative contamination and to prevent early passage of bowel content

through an anastomotic suture line while it is healing. • Drain tube was believed essential in any GIT surgery• Prolonged bed rest were recommended to facilitate

abdominal wall healing.

…but Evidence always trumps Dogma

DOGMA

EVIDENCE

An evidence-based concept for acceleration of postoperative recovery ,convalescence by a multimodal rehabilitation program

The term “fast track” was firstly used by Professor Henrik KehletIn 1990 MD, PhD, Surgical Gastroenterologist

Members of ERAS progrm• Nurses• Dietitians• Physiotherapists• Pain team• Anaesthetists• Surgeons• Hospital management

Pre-Admission• Counseling

• Oral Supplements

Pre-Operative• Admission on the day of surgery

• Preoperative fasting and Carbohydrate Loading• No Mechanical Bowel Preparation• Prophylaxis: DVT, Antibiotic

• Perioperative opioid sparing analgesiaAnesthesia• Normothermia

• Mid Thoracic Epidural Analgesia• Avoidance of fluid overload

SurgicalApproach: Laparoscopy/ Short Incision/ Transverse Incision

Avoid Surgical Drains or Nasogastric tubes

Post-Operative• Hydration

• Active, Multimodal and preventive pain control• Aggressive management of nausea and vomiting

• Early oral feeding and mobilization• Nutritional support

• Remove urinary catheters and drains• Discharge criteria

“Fast Track Suergery” Components

Pre-admissionPre admission counseling:

A clear explanation of what is to happen during hospitalizationExplanation of role of the patient about food intake, oral nutritional supplements and mobilization after surgery

Pre-Operative• Preoperative assessment and optimization of organ function seeks to

reduce operative risk.

• Alcohol and smoking cessation for a month preoperatively can reduce the incidence of complications, e.g., bleeding, wound infections, and cardiorespiratory complications .

• Bowel preparation leads to patient discomfort, dehydration, and electrolyte imbalance,and is no longer recommended in elective abdominal surgery . However, bowel preparation may have a role in selected patients such as those undergoing rectal resection .

•Modern fasting guidelines recommend that the duration of preoperative fasting should be 2 h for liquids and 6 h for solids .

• Preoperative nutrition and good carbohydrate diet reduces preoperative thirst, hunger and anxiety, and significantly reduce postoperative insulin resistance.

Intra-operativeIntraoperative fluid therapy Avoid Na and Fluid overload .Goal directed fluid therapy via Oesophageal Doppler(OD) monitoring. Fluid overload is associated with delayed gut function and increased complication rates.

Maintenance of normothermia is important for preventing sympathetic responses, cardiac arrhythmias, and wound complications.

Tubes and drainsNo routine use of drains , nasogastric tube.

Anasthesia epidural, spinal, or peripheral nerve block remains a key element of the FT program and has been associated with attenuated endocrine stress response, increased gut motility, reduced inflammatory response, and optimal pain relief, but its application must be procedure-specific. For lap. colectomy, spinal analgesia or patient-controlled analgesia may be superior to epidural analgesia within a FT program .

Short-acting opioids are commonly used in FT surgery in combination with regional anesthetic techniques to minimize the amount of anesthetics used and to facilitate recovery.

Minimally invasive techniquesShort, Transverse Incision,Laparoscopy reduce in-patient stays, lessen morbidity and lower postoperative pain.

oxygen therapy may reduce the risk of wound infection and anastomotic complications. Antimicrobial prophylaxis is recommended to prevent infectious complicationsAnticoagulants minimizes thromboembolic events

Post-operative Encourage Early Postoperative Oral Intake• Facilitates early return of bowel function,• Allows stopping of intravenous drips,• Aids mobilization, • Leads to faster recovery.• Reduces postoperative morbidity and is not associated with an increased

risk of anastomotic dehiscence

Early remove of nasogastric tube , drains and catheters

Early mobilizationBed rest • ↑ insulin resistance , muscle loss and risk of thromboembolism.• ↓ muscle strength, pulmonary function and tissue oxygenation .• The aim is for patients to be out of bed for 2 h on the day of surgery, and for 6

h a day until discharge.

Post operative painUsing• NSAIDs• Epidural and• local infiltrating anasthesia is better• Opiates are associated with decreased gut motility and delay recovery

Prevention of Postoperative Nausea and Vomiting (PONV) and ileus• PONV is unpleasant, delays gut function, affects mobility and has

metabolic consequences.• Give prophylactic anti-emetics i.e. Ondansetron during anesthesia

around 30 min before the end of surgery.• Ileus can be avoided by early ambulation ,laxatives, and electrolyte

balance.

Discharge criteria

• Patients can be discharged when they meet the following criteria:• Good pain control with oral analgesia• Taking solid food, no intravenous fluids• Independently mobile or same level as prior to admission• All of the above and willing to go home.

Is fast-track surgery safe and effective?

Evidence from clinical trials as well as expert opinions of surgeons in the field suggest that fast-track programs can result in beneficial outcomes for patients. In particular, optimising conditions before, during and after surgery can reduce the length of hospital stay for patients with no increase in readmission rates, morbidity or mortality.

The available evidence suggests that fast-track protocols are as safe as conventional treatment regimes.

Application of fast track surgery• Colorectal surgery• Bariatric surgery• Liver and pancreatic resection • Breast surgery• Urological surgery i.e Lap. Prostatectomy• Orthopedic operations “Hip and knee replacement”

Enhanced Recovery After Surgery

• Saves money• Saves resources• Saves time• With no inreased complication rate

Reference

• 1. Manual of Fast Track Recovery for Colorectal Surgery- Nader Francis, Robin H. Kennedy, Olle Ljungqvist, Monty G. Mythen

• 2. Enhanced recovery programme in colorectal surgery: Does one size fit all?- Alison Lyon, Christopher J Payne, Graham J MacKay World J Gastroenterol 2012 October 28; 18(40): 5661-5663

• 3. Multimodal Approach to control postoperative Pathophysiology and rehabilitation- Henrik Kehlet. Brit. J A 1997; 78: 606-617

• 4. ERAS (Enhanced Recovery after Surgery) in Colorectal Surgery- Raúl Sánchez-Jiménez, Alberto Blanco Álvarez, Jacobo Trebol López, Antonio Sánchez Jiménez, Fernando Gutiérrez Conde and José Antonio Carmona Sáez

• Zargar-Shoshtari K, Sammour T, Kahokehr A, Connolly AB, Hill AG (2009) Randomized clinical trial of the effect of glucocorticoids on peritoneal inflammation and postoperative recovery after colectomy. Br J Surg 96:1253–1261

Vignali A, Di PS, Orsenigo E, Ghirardelli L, Radaelli G, Staudacher C (2009) Effect of prednisolone on local and systemic response in laparoscopic vs. open colon surgery: a randomized, double-blind, placebo-controlled trial. Dis Colon Rectum 52:1080–1088

Schmidt SC, Hamann S, Langrehr JM, Hoflich C, Mittler J, Jacob D, Neuhaus P (2007) Preoperative high-dose steroid administration attenuates the surgical stress response following liver resection: results of a prospective randomized study. J Hepatobiliary Pancreat Surg 14:484–492

Sammour T, Kahokehr A, Chan S, Booth RJ, Hill AG (2010) The humoral response after laparoscopic versus open colorectal surgery: a meta-analysis. J Surg Res 164:28–37

Thank You All