[What is "Fast-track"-surgery?]

Fast-Tracking Patients Through the Diagnostic and Therapeutic Pathways of Intrathoracic Conditions: The Role of Uniportal Video-Assisted Thoracic Surgery

Fast-tracking patients in surgery has become standard in many hospitals. This allows for a shorter hospital stay and a complete organized pathway for treating patients. The operative trauma has an important role in the patient's recovery, as has the increasing use of minimally invasive procedures. In thoracic surgery, video-assisted thoracic surgery (VATS) procedures are aimed at reducing the operative trauma. One of the latest developments of VATS is represented by the uniportal approach, whose purpose is to reduce postoperative pain and morbidity. This article reviews the current literature and the authors' experience in combining uniportal VATS technique and fast-track surgery.

A Better Journey for Patients, a Better Deal for the NHS: The Successful Implementation of an Enhanced Recovery Program After Renal Transplant Surgery

OBJECTIVES

Our aim was to apply the principles of enhanced recovery in renal transplant recipients and to assess the changes in the quality of patient care and patient satisfaction.

MATERIALS AND METHODS

Our study included 286 consecutive renal transplant patients. Of these, 135 patients went through the enhanced recovery program and 151 patients had traditional recovery. Patient education and discharge planning were commenced on admission. For enhanced recovery, prolonged preoperative fasting was avoided by carbohydrate loading. Goal-directed fluid management was aided by transesophageal Doppler to avoid central line insertion. Intrathecal diamorphine and ultrasonography-guided transversus abdominis plane blocks were used to achieve adequate analgesia. Patients started oral intake a few hours postoperatively. The urinary catheter was removed 2 to 4 days after transplant.

RESULTS

The postoperative patient-controlled analgesia requirement for morphine was significantly reduced in the enhanced recovery versus traditional recovery group (median of 9.5 vs 47 mg; P < 0.001). The length of stay was significantly reduced for living-donor (median 5 vs 7 days; P < .001) and for deceased-donor transplant recipients (median 5 vs 8.5 days; P < 0.001) with enhanced recovery versus recipients who had traditional recovery. Implementing enhanced recovery saves £2160 per living-donor transplant and £3078 per deceased-donor transplant. In the enhanced recovery group, readmission within 10 days after transplant was 5%.

CONCLUSIONS

Our service evaluation demonstrated that enhanced recovery benefits both types of renal transplant (living and deceased grafts) procedures, with excellent patient satisfaction and reduction of hospital length of stay.

Do shorter lengths of stay increase readmissions after total joint replacements?

Background

Enhanced recovery after surgery protocols for total joint replacements (TJRs) emphasize early discharge, yet the impact on readmissions is not well documented. We evaluate the impact of a one-day length of stay (LOS) discharge protocol on readmissions.

Methods

We conducted a retrospective review of all primary TJRs (hip and knee) from April 2014 to March 2015. Patients who had adequate support to be discharged home were categorized into 2 groups, 1-day (n = 174) vs 2-day (n = 285) LOS groups. Patients discharged to rehabilitation were excluded (n = 196).

Results

Patients in the 1 day group were more likely to be younger (61.7 vs 64.8 years, P < .001), be male (56.3% vs 40.4%, P = .001), and have a lower body mass index (30.0 vs 31.4 kg/m², P = .012). One-day LOS patients had shorter surgical times (79.7 vs 85.6 minutes, P = .001) and more likely had spinal anesthesia (46.0% vs 31.2%, P = .001). The overall 30-day all-cause (2.3% vs 2.5%, P = .591) and 90-day wound-related (1.1% vs 1.1%, P = .617) readmission rates were equivalent between groups.

Conclusions

Early discharge does not increase readmissions and may help attenuate costs associated with TJRs. Further refinement of protocols may allow for more patients to be safely discharged on postoperative day 1.

Enhanced recovery after surgery (ERAS): an orthopaedic perspective

Enhanced recovery after surgery (ERAS) is a programme that aims to improve the care of elective surgical patients. Accelerated care pathways are delivered using a multidisciplinary approach, leading to reduced lengths of hospital stay, improved quality of treatment, and better outcomes. These programmes have gained considerable popularity in orthopaedics recently, however their widespread adoption remains to be seen. This article highlights the key evidence concerning ERAS in orthopaedic surgery.

'23 h Model' for breast surgery: an early experience

The principles of fast track surgery are well established in colorectal surgery. It is an evidence based model aimed at reducing length of stay, convalescence and morbidity by optimising both clinical and organisational factors. Despite this, the implementation of fast track surgery in breast cancer patients has been slow. The 23 h discharge model for breast cancer surgery patients has been outlined by the NHS Improvement Programme and is a breakthrough from traditional inpatient care. This paper outlines the early experience of implementation of this model in a single institution during a 3-month audit period. Over 80% of patients undergoing non-reconstructive breast surgery were discharged safely within '23 h'. This suggests that good communication links, reorganisation of existing resources, active user involvement (both patients and clinical team) and strong project management ensures fast-tracking to be safe for the patient with significant economic benefits for the hospital.

[Fast track in vascular surgery]

Vascular comorbidities are common in vascular surgery, being associated with perioperative complications. Since it was demonstrated that the postoperative course could be optimized by introduction of the fast track concept in general surgery, application to vascular surgery may also be of benefit. The fast track concept was introduced in our institution on May 1st 2008 with special adjustments for vascular surgery. The authors describe the development and implementation of a clinical pathway, which proved to be of value in vascular surgery.

Preoperative stress and anxiety in day-care patients and inpatients undergoing fast-track surgery

BACKGROUND

To investigate preoperative levels of stress and anxiety in day-care patients and inpatients undergoing surgical interventions.

METHODS

Before induction of anaesthesia, the degree of stress and anxiety was assessed in 135 patients using stress and anxiety questionnaires, bio-feedback, physiological measures, and serum levels for stress variables. Questionnaire responses and physiological measures such as arterial pressure, heart rate, skin conductance, cortisol, and catecholamine levels were compared for day-care patients and inpatients.

RESULTS

Significant preoperative anxiety was reported by 34 (45.3%) inpatients and 23 (38.3%) day-care patients. Personal responses in stress and anxiety questionnaires and mean values of arterial pressure and heart rate did not differ significantly in day-care patients when compared with inpatients. Correlation between deviations in plasma cortisol concentrations from normal diurnal distribution and anxiety scores and stress scores was also similar, and the relative increase in preoperative stress variables and measures observed in day-care patients and inpatients was also comparable. Bio-feedback measurements revealed significantly higher preoperative skin conductance (P<0.001) in day-care patients than in inpatients, indicating increased vegetative stress responses.

CONCLUSIONS

Preoperative anxiety and stress are common in surgical patients. Questionnaires and bio-feedback measurements may help to assess the degree of patients' burdens. Surgeons should be aware of the personal anxiety of patients and consider patient preferences when deciding who should undergo fast-track surgery in day-care.

Fast-Track-Rehabilitation am Beispiel der Kolonchirurgie

Fast-track rehabilitation refers to an interdisciplinary multimodal procedure to improve and accelerate recovery and avoid perioperative complications. The concept aims at reducing morbidity and discharging patients faster. It includes preoperative patient information, atraumatic surgical technique, stress reduction, pain therapy mostly via regional anesthetic techniques (frequently, thoracic epidural anesthesia), optimized fluid and temperature management, early enteral feeding, prophylaxis of gastrointestinal atony and postoperative nausea and vomiting, fast postoperative patient mobilization, and earlier hospital discharge. Fast-track protocols exist for all kind of surgical procedures but are best established for colon surgery.

Management of complications in surgery of the colon

BACKGROUND

General surgeons are frequently confronted with colorectal diseases in their daily practice, whereby colorectal cancer is the second most common malignant tumour, with almost 5000 new cases every year in Austria. The incidence of benign colon disorders requiring surgery (e.g. colon polyps, sigmoid diverticulitis) is also increasing. The first aim in colon surgery should be to avoid complications and if they occur to treat them properly.

METHODS

We basically distinguish between general and special complications. As general complications, prevention of malnutrition and support of the immune system should receive special attention. As the number of elderly patients increases, so does the risk not only of thrombembolic complications but also of critical cardiocirculatory situations, and renal and hepatic failure. Special complications depend either on the type of surgery (laparoscopic assisted, conventional open surgery) or the techniques employed (stapled, hand sutured). Handling of the tissue also plays a major role (e.g. dry versus wet pads).

RESULTS

Shortening of the postoperative stay decreases both hospital costs and the incidence of infections, meaning that minimally invasive surgery and postoperative "fast track nutrition" should be promoted. Emergency operations should be avoided (e.g. bridging through colonic stents), as morbidity and mortality are clearly increased in comparison to (semi-) elective operations. During the operation itself, new equipment and techniques (such as Ultracision®, Ligasure®) as well as a well coordinated team help to reduce complications and duration of surgery.

CONCLUSIONS

To avoid is better than to repair. If complications do occur, appropriate surgical and intensive - care measures should be taken immediately.

Fast-track surgery in laparoscopic radical prostatectomy: basic principles

Fast-track surgery describes innovative treatment concepts ensuring a faster convalescence phase. The aim of this study was to allow hospital discharge 3 days after surgery without additional complications in patients receiving LRPE for localized prostate cancer. Twenty-five patients each were randomized in the study groups to verify if a fast-track regimen could be transferred into clinical routine. The perioperative data, early complications, hospital stay as well as readmission rate were analyzed. The mean postoperative stay was 3.6 days in the fast-track group versus 6.7 days in the conventional group. The overall complications were significantly less in the fast-track procedure. The readmission rate was low and not significant. Patients receiving an LRPE benefit from a suitable fast-track concept. The postoperative hospital stay could be shortened nearly by half with a significantly decreased overall complication rate. Thus, fast-track concepts might contribute to saving resources in the long term. However, more evidence based on larger prospective trials is needed to achieve optimal quality of life for patients perioperatively.

["Fast-track surgery": Perioperative management]

The multimodal therapeutic concept of fast-track surgery is directed against the pathophysiologic functional changes following elective surgery. This concept has been proven to reduce postoperative morbidity and convalescence. This benefit is based on an interdisciplinary approach by surgeons, anaesthesiologists, nurses, and physiotherapy staff to optimise perioperative care in order to decrease surgically-induced stress. Fast-track surgery after elective colorectal surgery has been shown to reduce the rate of postoperative complications and shorten hospital stay significantly. A prerequisite for successfully implementing this concept is the willingness of the participating surgeons to abandon conventional traditions. In addition to abdominal procedures, the basic concept of fast-track surgery has been successfully instituted in other surgical fields, such as urology.

[Fast-track surgery in radical retropubic prostatectomy. First experiences with a comprehensive program to enhance postoperative convalescence]

Fast-track surgery is a comprehensive program for the optimization of perioperative care in elective surgery reducing potential postoperative complications and speeding up convalescence. Recent data from randomized colon resection trials emphasize that fast-track surgery is possible in most major operations. Our initial results in radical retropubic prostatectomy fast-track surgery have been encouraging. Fast-track surgery in major urological operations needs validation using randomized trials.