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Medical Meeting Reports

American College of Surgery Clinical Congress

October 10-15, 1999

font=>by Karen Sandrick

Douglas Wilmore, MD, of Harvard Medical School, Boston, Massachusetts, chaired a panel discussion by surgeons from the United States and Europe who are adopting a multimodal accelerated postoperative recovery program to decrease pain and ileus and cut hospitalization to 23-72 hours for major elective abdominal procedures. Fast tracking aims to accelerate postoperative recovery by taking advantage of knowledge about the stress response to surgery to prevent the postoperative cascade that prolongs recuperation. The fast tracking approach is not a response to managed care pressures to minimize costly hospital days.

Evolution of the Fast Track Approach

Dr. Wilmore pointed out that the last decade has seen an evolution in perioperative care. In addition to laparoscopic techniques, surgeons have been using epidural regional anesthetic agents to reduce the stress response associated with elective surgery. Surgeons also have taken advantage of new pharmacologic agents that control nausea, vomiting, gastric ileus, and infection, thereby drastically reducing the incidence of postoperative complications. While any one of these treatments rarely causes a significant impact on patient outcomes, a multimodal approach appears to shorten surgical convalescence following major operative procedures.

What Is Fast Track Surgery?

Jonathan Meakins, MD, of McGill University, Montreal, Quebec, explained that multimodal fast tracking involves thorough patient education, a multidisciplinary team approach to surgical management, epidural anesthetic administration, maintenance of the patient's body temperature in the OR, and early nutrition and ambulation after the procedure.

Richard Thirlby, MD, of Virginia Mason Medical Center, Seattle, stressed the importance of preoperative patient education, including written guidelines that describe what the hospital stay will be like for the patient, typed--not hand-written bowel preps--and a compete set of discharge instructions. He also observed that epidural anesthesia is a key factor because it blocks the painful stimulus that interferes with postoperative bowel function and contributes to ileus.

Challenging Traditional Approaches

The combination of therapeutic modalities in fast tracking is helpful in overcoming intraoperative factors that tend to delay recuperation. Recuperation delaying therapies include blood transfusions which suppress the immune system and hypothermia which has been shown to increase the length of hospitalization by more than two days, particularly for elderly surgical patients.

The trend toward fast tracking is challenging a number of surgical traditions including routine use of nasogastric tube decompression. One meta-analysis of 4,000 patients demonstrated that routine use of nasogastric tubes after laparotomy increased the incidence of complications, such as pneumonia and atelectesis, and decreased the time to oral feeding.

The 48-Hour Colectomy

Henrik Kehlet, MD, of Hvidovre University Hospital, Hvidovre, Denmark, who has been investigating the effect of epidural anesthetics on the modification of the surgical stress response since the 1970s, reported on the first 60 consecutive colectomy patients to be placed on an accelerated multimodal postoperative recovery program at his institution. The median age of the patients was 74 years, and most of the patients in the study had complicating diseases; only 18 were considered to have no significant concomitant illnesses.

The median hospital stay for patients in the study was two days. All but three of the patients had a bowel movement within two days, and none had postoperative ileus. Within 24 to 48 hours of surgery, the patients were spending between five and six hours, on average, out of bed, and on the day of discharge, patients were spending an average of ten hours out of bed.

The most frequent complication in the first 30 days after colectomy was urinary retention, which occurred in 11% of patients. However, urinary retention tended to occur early in the postoperative period, and it posed no long-term problem. Other complications were low in incidence: only 3% of patients suffered infection or postoperative bleeding, 3% had anastomotic leakage, and none had cardiopulmonary compromise.

Ortho Biotech

Funded through an unrestricted educational grant by Ortho Biotech.

Dr. Kehlet acknowledged that more study of the fast track approach to colectomy is needed. However, he said this study showed that accelerated rehabilitation and pain control is safe. He also questioned the need for minimally invasive techniques if fast track open surgery can achieve similar postoperative lengths of stay. He therefore welcomes blinded trials that pit fast track open surgery against laparoscopic elective procedures.

For professional correspondence, contact Dr. Wilmore at wilmore@sciam.com.

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