The future of fast‐track surgery A Comparative Study of ‘Fast-Track’ Versus Traditional Peri-Operative Care Protocols in Gastrointestinal Surgeries Implementing Fast-Track Protocol for Colorectal Surgery: A Prospective Randomized Clinical Trial Fast-track in open intestinal surgery: prospective randomized study (Clinical Trials Gov Identifier no. NCT00123456). Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study. Fast-Track Surgery May Reduce Complications Following Major Colonic Surgery [Tolerance of accelerated postoperative rehabilitation following intestinal resections]. A fast-track program reduces complications and length of hospital stay after open colonic surgery. Fast-track colorectal surgery: protocol adherence influences postoperative outcomes Implementation of a Fast-Track Clinical Pathway Decreases Postoperative Length of Stay and Hospital Charges for Liver Resection Randomized Trial on Fast Track Care in Colorectal Surgery for Deep Infiltrating Endometriosis. Faster recovery of gastrointestinal transit after laparoscopy and fast-track care in patients undergoing colonic surgery. Fast-track hip and knee replacement — what are the issues? [Fast track rehabilitation in colonic surgery: results of a prospective trial]. Perioperative strategy in colonic surgery; LAparoscopy and/or FAst track multimodal management versus standard care (LAFA trial) Safety and Efficacy of Fast-track Surgery in Laparoscopic Distal Gastrectomy for Gastric Cancer: A Randomized Clinical Trial Fast Track Postoperative Management after Elective Colorectal Surgery: A Controlled Trail Enhanced Recovery After Surgery Protocols Are Valuable in Pancreas Surgery Patients. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. Fast-Track Failure After Cardiac Surgery: External Model Validation and Implications to ICU Bed Utilization Surgical Stress Response and Postoperative Immune Function After Laparoscopy or Open Surgery With Fast Track or Standard Perioperative Care: A Randomized Trial Fast-track Surgery in Real Life: How Patient Factors Influence Outcomes and Compliance With an Enhanced Recovery Clinical Pathway After Colorectal Surgery Fast-Track Surgery Improves Postoperative Clinical Recovery and Immunity After Elective Surgery for Colorectal Carcinoma: Randomized Controlled Clinical Trial
Since its introduction in the 1990s , the concept of multimodal perioperative care ( fast-track surgery , enhanced recovery programmes ) has gained widespread acceptance and is now considered as a st and ard of care . Most studies that support this approach relate to colorectal surgery , but similar data have been published across surgical specialties with major economic benefits 1–4 . The implementation process has been described in detail and is essentially based on the simple question : ‘ Why is the postoperative patient in hospital today?’1,5 . The relevant question may therefore be asked – what next ? Postoperative length of stay is often seen as the key outcome for fast-track surgery and , although this may not always be appropriate , whatever is used as a primary outcome measure must be justified adequately . It should also be emphasized that significant progress in fast-track care dem and s inclusion and implementation of all of its basic components . Many studies have not implemented the most important aspects of the care programmes that were originally described , including patient information , effective thoracic epidural analgesia with sufficient local anaesthetic that facilitates early mobilization , reduced ileus and rapid re introduction of oral feeding , or the use of non-opioid analgesia , where appropriate , in open or minimally invasive surgery . An important issue that needs to be addressed in future is detailed analysis of ‘ medical ’ versus ‘ surgical ’ morbidity6 . To improve further our underst and ing of perioperative risk , future studies must analyse how one specific complication might lead to another : for instance , whether a pneumonia or myocardial infa rct ion led to an anastomotic dehiscence ; or a wound dehiscence with reoperation led to a subsequent pneumonia , myocardial infa rct ion or thromboembolic complication6 . Initial ‘ medical ’ morbidity may depend on perioperative care principles and pre-existing comorbidity , in contrast to an initial ‘ surgical ’ complication , which may depend on surgical technique , and therefore require a different approach from fast-track methodology . How might the fast-track approach evolve further , as surgeons perform an ever-increasing number of major procedures in older patients with comorbidities , with greater risks of postoperative complications , prolonged hospital stay and death6 ? Preoperative evaluation of operative risk may not be helpful unless evidence -based perioperative interventions are available and instituted . Thus , the specific role of preoperative morbidity , such as smoking , diabetes and cardiopulmonary disease , in determining the risk of postoperative morbidity needs to be reassessed in studies with a fully implemented fast-track procedure-specific programme6 . We also need to have a second look at the relative roles of the different components of the fast-track programme ( for example type of analgesia and fluid management1,5 ) and analyse where progress can be made in order to reduce perioperative risk and morbidity , instead of focusing on length of stay as the primary outcome . The surgical stress response is proportional to the degree of insult and the main factor that contributes to postoperative organ dysfunction1,2 . Every effort should therefore be made to reduce those responses that are undesirable . Regional anaesthetic techniques have a powerful effect on the catabolic response , reducing cardiac dem and s , pain , pulmonary dysfunction and ileus .  Regional anaesthesia should be used whenever possible on a procedure-specific basis7 . Inflammatory responses contribute to pain , fatigue and organ dysfunction . They can be modified pharmacologically by preoperative glucocorticoids8 . Significant reductions in pain , nausea and vomiting , and early fatigue have been demonstrated , facilitating early recovery , so far without demonstrable side-effects . More procedure-specific and dosefinding studies are required . A single preoperative glucocorticoid dose in a larger amount than used for conventional nausea and vomiting prophylaxis might , for instance , be an important contributory factor to improving fast-track programmes in high-risk patients . Minimally invasive surgery also reduces the inflammatory response , although the contribution that this plays in the context of fast-track programmes in colonic surgery is difficult to interpret , as the care programmes used in the ‘ open ’ groups have often not been fully implemented6,9,10 . Therefore , future efforts to assess early postoperative outcome effects of minimally invasive surgery should include r and omized studies with fully implemented fasttrack programmes11 . Newer developments in minimally invasive Introduction A ‘ fast-track protocol ’ in surgery suggests the application of evidence -based practice s to expedite patient recovery . It has shown to reduce hospital stay , hasten recovery as well as facilitate earlier return to work . It has a considerable impact in reducing healthcare costs . The basic tenet is to treat the patient ’s disease by minimal disturbance of their physiology . The protocol encompasses pre-operative , intra-operative and post-operative interventions which when carried out together would show maximal benefits . The surgeon is usually the leader of the team managing the patient , but it can not be over-emphasised that this is a multi-disciplinary team approach . Material s and Methods We conducted a prospect i ve interventional study to investigate whether ‘ fast-track ’ surgery protocol s improve patient outcome when compared to traditional peri-operative care followed at our institute . By doing so , we observed that the patients who underwent ‘ fast tracking ’  required lesser analgesia , had earlier ambulation , earlier return of intestinal motility , were free from tubes , catheters and drains earlier and lastly were discharged earlier . This was achieved without a rise in complications or re-admissions . Results / Conclusion The results have proved that implementing the fast-track protocol for gastrointestinal surgeries is not only safe and effective , but also improves patient outcome Background Fast-track protocol s are followed by an enhanced recovery , early return to bowel function and to complete nutrition , and a reduced hospital stay . Our study was design ed to implement fast-track protocol in our university hospital . Methods The 96 consecutive patients with colorectal neoplasm included in the study were r and omized in two equal groups : group 1 ( FT ) included patients undergoing colorectal surgery in a fast-track protocol , and group 2 ( C ) included patients undergoing colorectal surgery with a conventional care protocol .  As with other fast-track protocol s , our protocol included carbohydrate fluids load before operation , early mobilization and oral feeding , regular prokinetics , and multimodal postoperative analgesia .  Time to restoration of bowel function , to complete mobilization and feeding , length of hospital stay , and incidence of complications and readmissions were monitored . Results Time to mobilization , restoring of bowel function , and complete oral feeding were significantly shorter with fast-track protocol ( p = 0.001 , p = 0.042 , and p = 0.01 , respectively ) . Hospital stay also was shorter in the fast-track group ( p = 0.001 ) . The incidence of complications did not significantly differ with the study groups . Conclusions In our study , fast-track protocol result ed in a shorter time to mobilization , complete feeding , and discharge from hospital . Fast-track protocol did not increase the incidence of complications . However , we consider that our data require further confirmation with powered multicenter national studies BACKGROUND Studies have shown the value of using fast-track postoperative recovery . St and ard procedures ( non-fast-track strategies ) remain in common use for perioperative care . Few prospect i ve reports exist on the outcome of fast-tracking in Central Europe . The aim of our study was to assess the effect and safety of our own fast-track protocol with regard to the postoperative period after open bowel resection . PATIENTS AND METHODS One hundred and five patients with ASA score I-II scheduled for open intestinal resection in the period April 2005-December 2007 were r and omly selected for the fast-track group ( FT ) and non-fast-track group ( non-FT ) . A design ed protocol was used in the FT group with the emphasis on an interdisciplinary approach . The control group ( non-FT ) was treated by st and ard established procedures .  Postoperative pain , rehabilitation , gastrointestinal functions , postoperative complications , and post-op length of stay were recorded . RESULTS Of 105 patients , 103 were statistically analyzed . Patients in the FT group ( n=51 ) and non-FT group ( n=52 ) did not differ in age , surgical diagnosis , or procedure . The fast-track procedure led to significantly better control of postoperative pain and faster restoration of GI functions ( bowel movement after 1.3 days vs. 3.1 , p<0.001 ) . Food tolerance was significantly better in the FT group and rehabilitation was also faster . Hospital stay was shorter in the FT group - median seven days ( 95 % CI 7.0 - 7.7 ) versus ten days ( 95 % CI 9.5 - 11.3 ) in non-FT ( p<0.001 ) . Postoperative complications within 30 postoperative days were also significantly lower in the FT group ( 21.6 vs. 48.1 % , p=0.003 ) . There were no deaths and no patients were readmitted within 30 days . CONCLUSIONS Following the FT protocol helped to reduce frequency of postoperative complications and reduced hospital stay . We conclude that the FT strategy is safe and effective in improving postoperative outcomes OBJECTIVE A minimal extracorporeal circulation ( MECC ) circuit integrates the advances in cardiopulmonary bypass ( CPB ) technology into a single circuit and is associated with improved short-term outcome . The aim of this study was to prospect ively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures . DESIGN Prospect i ve r and omized study . SETTING All patients scheduled for elective coronary artery surgery were evaluated , excluding those considered particularly high risk for fast-track failure . The fast-track protocol included careful preoperative patient selection , a fast-track anesthetic technique based on minimal administration of fentanyl , surgery at normothermia , early postoperative extubation in the cardiac recovery unit , and admission to the cardiothoracic ward within the first 24 hours postoperatively . PARTICIPANTS One hundred twenty patients were assigned r and omly into 2 groups ( 60 in each group ) . INTERVENTIONS Group A included patients who were operated on using the MECC circuit , whereas patients in Group B underwent surgery on conventional CPB . MEASUREMENTS AND MAIN RESULTS Incidence of fast-track recovery was significantly higher in patients undergoing MECC ( 25 % v 6.7 % , p = 0.006 ) . MECC also was recognized as a strong independent predictor of early recovery , with an odds ratio of 3.8 ( p = 0.011 ) . Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion , duration of inotropic support , need for an intra-aortic balloon pump , and development of postoperative atrial fibrillation and renal failure . CONCLUSIONS MECC promotes successful early recovery after elective coronary revascularization procedures , even in a nondedicated cardiac intensive care unit setting Purpose Fast-track ( enhanced recovery ) care pathways for colonic surgery are becoming increasingly popular ; however , there have been concerns regarding protocol compliance , high readmission rates , and also the true impact on morbidity rates with these protocol s. This study was conducted to assess the impact of a fast-track program for colonic surgery on hospital stay , complications , and readmission rates . Methods From December 2005 to March 2007 , consecutive patients undergoing colonic surgery were prospect ively studied . The comparison group consisted of a comorbidity-matched group of patients who had undergone similar surgery before establishment of the fast-track program .  Results Fifty patients were included in each group . Groups were comparable at baseline . The fast-track group received significantly smaller amounts of intraoperative and postoperative intravenous fluids , were fed earlier , mobilized earlier , passed flatus earlier , and were discharged earlier than the comparison group ( 4 vs. 6.5 days , P < 0.001 ) . The numbers of patients with urinary infections ( 2 vs. 12 , P = 0.008 ) , ileus ( 5 vs. 18 , P = 0.005 ) , and cardiopulmonary complications ( 11 vs. 21 , P = 0.032 ) were significantly lower in the fast-track group . There was no difference in the rate of readmission . Conclusion Fast-track is a safe and effective approach for reducing hospital stay and morbidity following major colonic surgery INTRODUCTION Modern procedures in peri-operative care arising from evidence -based medicine improve postoperative results . Their acceptance is however not a common clinical practice at most surgical centers . AIM The aim of our study was to design a protocol and introduce it into the praxis . The subject of announcement is tolerance of protocol in our conditions . PATIENTS AND METHOD Prospect i ve r and omized study included patients who were operated on ( open bowel resection ) at Department of Surgery in period 4/2005 - 12/2007 . They were r and omized in fast track group ( n=53 ) and non-fast track group ( n=52 ) .  Protocol with accelerated recovery was used in the fast track group ( FTG ) and we used traditional approach in the not-fast track ( non-FTG ) . Results were statistically evaluated , 2 patients ( FTG ) were excluded from analysis for protocol failure ( protocol was non kept by anesthesiologist in 1 patient and by the nurse in the second patient ) . Protocol and informed consent form was approved by the Hospital Ethics Committee . RESULTS Both groups did not differ in age , diagnosis and length of surgery . Analgesia was controlled significantly better in FTG ; similarly oral intake tolerance was higher in this group ( day of surgery -- mean value 634 ml versus 304 ml ) . Restoration of bowel functions was also faster in interventional group ( mean time 2.1 versus 3.9 days ) . Frequency of postoperative complications was lower and hospital stay was shorter ( median 7.0 versus 9.0 days , p < 0.001 ) . CONCLUSION Design ed fast track protocol of postoperative recovery could be introduced in clinical praxis in terms of study . Patients ' tolerance was very good . Application of accelerated recovery procedures is possible in our conditions but it means primarily to overcome worse tolerance of attending personnel BACKGROUND & AIMS A fast-track program is a multimodal approach for patients undergoing colonic surgery that combines stringent regimens of perioperative care ( fluid restriction , optimized analgesia , forced mobilization , and early oral feeding ) to reduce perioperative morbidity , hospital stay , and cost . We investigated the impact of a fast-track protocol on postoperative morbidity in patients after open colonic surgery . METHODS A r and omized trial of patients in 4 teaching hospitals in Switzerl and included 156 patients undergoing elective open colonic surgery who were assigned to either a fast-track program or st and ard care . The primary end point was the 30-day complication rate . Secondary end points were severity of complications , hospital stay , and compliance with the fast-track protocol . RESULTS The fast-track protocol significantly decreased the number of complications ( 16 of 76 in the fast-track group vs 37 of 75 in the st and ard care group ; P = .0014 ) , result ing in shorter hospital stays ( median , 5 days ; range , 2 - 30 vs 9 days , respectively ; range , 6 - 30 ; P < .0001 ) . There was a trend toward less severe complications in the fast-track group . A multiple logistic regression analysis revealed fluid administration greater than the restriction limits ( odds ratio , 4.198 ; 95 % confidence interval , 1.7 - 10.366 ; P = .002 ) and a nonfunctioning epidural analgesia ( odds ratio , 3.365 ; 95 % confidence interval , 1.367 - 8.283 ; P = .008 ) as independent predictors of postoperative complications . CONCLUSIONS The fast-track program reduces the rate of postoperative complications and length of hospital stay and should be considered as st and ard care . Fluid restriction and an effective epidural analgesia are the key factors that determine outcome of the fast-track program Purpose This single-center prospect i ve cohort study , conducted outside of a clinical trial , tried to identify the importance of each fast-track surgery procedure and protocol adherence level on clinical outcomes after colorectal surgery . Methods From a prospect ively maintained data base , 606 patients who underwent elective laparoscopic or open colorectal resection within a well established fast-track surgery ( FT ) protocol , between 2005 and 2011 , were identified . Univariate and multivariate analysis were performed to assess the relationship between each FT procedure with an adherence rate < 100 % and the outcome variables ( length of stay — LOS , 30-day morbidity and readmission rate ) . Patients were divided into four adherence level groups to FT procedures —100 % , 85–95 % , 70–80 % , and < 65 % . Each adherence group was compared with the other groups to evaluate differences in clinical outcome variables . Results Group comparisons revealed that higher levels of FT protocol adherence corresponded to significantly improved LOS and morbidity rates . Readmission rates were only significantly different between the full fast-track pathway and the less implemented groups . Multivariate analyses revealed that the fast removal of bladder catheter positively influenced length of stay ( p < 0.0001 ) and 30-day morbidity ( p < 0.0001 ) . Laparoscopy surgery , no drain positioning and enforced mobilization improved LOS ( p = 0.027 , p < 0.0001 , p = 0.002 , respectively ) . Early solid feeding improved LOS ( p < 0.0001 ) , morbidity ( p < 0.0001 ) and readmission rate ( p = 0.011 ) . Conclusion Postoperative outcomes after colorectal surgery are directly proportional to FT protocol adherence . The early removal of the bladder catheter and early postoperative solid feeding independently influenced the length of hospital stay and 30-day morbidity rates A fast-track clinical pathway is design ed to streamline patient care delivery and maximize cost effectiveness . It has decreased postoperative length of stay ( LOS ) and hospital charges for many surgical procedures . However , data on clinical pathways after liver surgery are sparse . This study examined whether use of a fast-track clinical pathway for patients undergoing elective liver resection affected postoperative LOS and hospital charges . A fast-track clinical pathway was developed and implemented by a multidisciplinary team for patients undergoing liver resection . Between July , 2007 and May , 2008 , a total of 117 patients underwent elective liver resection :  the fast-track clinical pathway ( education of patients and families , earlier oral feeding , earlier discontinuation of intravenous fluid , no drains or nasogastric tubes , early ambulation , use of a urinary catheter for less than 24 h and planned discharge 6 days after surgery ) was studied prospect ively in 56 patients ( postpathway group ) . These patients were compared with the remainder who had usual care ( prepathway group ) . Outcome measures were postoperative LOS , perioperative hospital charges , intraoperative and postoperative complications , mortality , and readmission rate .  Among all patients , 69 ( 59 % ) had complicating diseases and /or a history of surgery and 24 patients belonged to American Society of Anesthesiologists grade III – IV . Compared with the prepathway group , the postpathway group had a significantly shorter postoperative LOS ( 7 vs. 11 days , P < 0.01 ) . The average perioperative hospital charges were RMB 26,626 for patients in the prepathway group and only RMB 21,004 for those in the postpathway group ( P < 0.05 ) , with no differences in intraoperative and postoperative complications ( P = 0.814 ) , mortality ( P = 0.606 ) , and readmission rate ( P = 0.424 ) . Implementation of the fast-track clinical pathway is an effective and safe method for reducing postoperative LOS and hospital charges for high-risk patients undergoing elective liver resection . The result supports the further development of fast-track clinical pathways for liver surgical procedures STUDY OBJECTIVE To study the application of a fast-track care protocol in colorectal surgery for deep infiltrating endometriosis . Bowel endometriosis is an infrequent but not rare condition that often needs intestinal surgery and imposes a high economic burden on society . DESIGN Prospect i ve r and omized trial ( Canadian Task Force classification I ) . SETTING Tertiary referral center . PATIENTS Two hundred twenty-seven patients with preoperative evidence of bowel endometriosis . INTERVENTIONS We r and omly assigned 227 patients with preoperative evidence of bowel endometriosis to a fast-track protocol ( no preoperative bowel preparation , early restoration of diet , no postoperative antibiotics , and early postoperative mobilization ) or conventional care for laparoscopic intestinal surgery . R and omization was obtained on a double-blind , date -based schedule , and all procedures were performed by a homogenous group of expert surgeons . Surgical outcomes and a health economic evaluation were assessed . MEASUREMENTS AND MAIN RESULTS The primary outcome was hospital stay . Patient 's well-being and intraoperative and postoperative complications up to 30 days after surgery were also assessed . Subsequently , direct medical costs were analyzed . Patients assigned to the fast-track protocol were discharged earlier ( median 3 vs 7 days , p < .001 ) with no significant differences in subjective well-being ( p = .55 ) . Operative details , postoperative complications , and need of temporary ileostomy were similar ( p = .89 ) between groups as well as readmission rates within 30 days ( p = .69 ) . The application of a fast-track protocol result ed in an overall significant reduction of costs ( USD 6699 vs 8674 , p < .01 ) , and differences were more evident in cases of protective stoma ( 7652 vs 8793 , p < .05 ) and surgery with postoperative complications ( 10 835 vs 14 005 , p < .01 ) . CONCLUSION The application of a fast-track care protocol for laparoscopy in cases of pelvic and intestinal endometriosis does not increase the risk of complications and ensures a reduction of medical costs BACKGROUND & AIMS Postoperative ileus is characterized by delayed gastrointestinal ( GI ) transit and is a major determinant of recovery after colorectal surgery . Both laparoscopic surgery and fast-track multimodal perioperative care have been reported to improve clinical recovery . However , objective measures supporting faster GI recovery are lacking . Therefore , GI transit was measured following open and laparoscopic colorectal surgery with or without fast-track care . METHODS Patients ( n = 93 ) requiring elective colonic surgery were r and omized to laparoscopic or conventional surgery with fast-track multimodal management or st and ard care  , result ing in 4 treatment arms . Gastric emptying and colonic transit were scintigraphically assessed from days 1 to 3 in 78 patients and compared with clinical parameters such as time to tolerance of solid food and /or bowel movement and time until ( ready for ) discharge . RESULTS A total of 71 patients without mechanical bowel obstructions or surgical complications requiring intervention were available for analysis . No differences in gastric emptying 24 hours after surgery between the different groups were observed ( P = .61 ) . However , the median colonic transit of patients undergoing laparoscopic/fast-track care was significantly faster compared with the laparoscopic/st and ard , open/fast-track , and open/st and ard care groups . Multiple linear regression analysis showed that both laparoscopic surgery and fast-track care were significant independent predictive factors of improved colonic transit . Both were associated with significantly faster clinical recovery and shorter time until tolerance of solid food and first bowel movement . CONCLUSIONS Colonic transit recovers significantly faster after laparoscopic surgery and the fast-track program ; laparoscopy and fast-track care lead to faster recovery of GI motility and improve clinical recovery Surgical injury is followed by pain , stress-induced catabolism , impairment of organ function , and a risk of thromboembolism and impaired cognitive function . These events may contribute to complications , a need for prolonged hospitalization , postoperative fatigue , delayed convalescence , and the need for rehabilitation . Optimization of the individual care components in perioperative care ( the fast-track methodology ) reduces the need for hospitalization , morbidity , and prolonged convalescence , with subsequent economic savings ( Kehlet and Wilmore 2008 ) . Correspondingly , improvement in perioperative care has led to a reduced stay in hospital after total hip arthroplasty ( THA ) and total knee arthroplasty ( TKA ) , which is now only about 3 days in many centers . The main question that remains to be answered is whether further improvement can be made and whether these operations can be performed on an ambulatory or semi-ambulatory basis without any increased risk of morbidity or cardiopulmonary and thromboembolic complications , long-term cognitive dysfunction , pain , and need for rehabilitation . Thus , a multidisciplinary collaboration has been established in 5 dedicated public Danish hospitals with established fast-track THA and TKA in order to optimize perioperative care to require only 1–2 days of hospitalization with no increase in post-discharge pain , morbidity , and rehabilitation requirements ( Figure ) . To this end , we concentrated on  perioperative pain management , optimization of transfusion strategies , strategies for postoperative rehabilitation , requirements for postoperative thromboembolic prophylaxis , and safety aspects ( re-admissions , hip dislocation , and knee stiffness ) . Effective postoperative pain relief is a prerequisite for a successful fast-track recovery . Although continuous peripheral nerve blocks are currently the most effective analgesic techniques ( Ilfeld et al. 2008a , b ) , they are dem and ing in terms of expertise and there is a risk of muscle paralysis . Efforts have therefore been made recently to improve local wound infiltration and infusion techniques . Although promising , more research is required to better define these techniques regarding dose-volume relationships , placement and types of catheters , duration , and safety aspects ( Rostlund and Kehlet 2007 ) . There will be more focus on post-discharge pain , which remains a problem in many patients . Furthermore , research will concentrate on mechanisms and predictors of the large inter-individual variability in the degree of postoperative pain , which may be related to the inflammatory response and genes associated with pain . Such knowledge should facilitate pain management , leading to differential use of analgesic principles in low pain responders and high-pain responders . Blood transfusion is indicated when a patient 's limit concerning — or physiological adaptation to — progressive normovolemic anemia is reached , but there are no specific data from THA and TKA . Data from hip fracture surgery have shown that postoperative anemia impedes functional mobility and that a liberal transfusion strategy reduces morbidity ( Foss et al. 2009 ) . Since modern blood transfusion is safer than before , large r and omized studies with high and low transfusion thresholds will be performed in cardiovascular high-risk patients after THA , with morbidity and functional recovery as primary outcome measures . Postoperative rehabilitation after THA and TKA has been st and ard despite the fact that there has been little evidence on the optimal type of physiotherapy , when it should be started , and for how long ( Minns Lowe et al. 2007 , 2009 ) . Previous r and omized studies have been inconclusive and they were based on relatively long-term hospitalization ( 7–12 days ) ; they are therefore not applicable to fast-track THA and TKA . Over the last decade , many industry-sponsored trials have documented the need for prolonged thromboembolic prophylaxis ( 10–30 days ) , mostly based on surrogate outcomes and with relatively small effects on clinical manifestations of thromboembolism ( Geerts et al. 2008 ) . A common characteristic of these studies has been a relatively long hospital stay ( 6–12 days or more ) . Since postoperative immobilization is a well-known risk factor for postoperative thromboembolism , the need for prolonged thromboembolic prophylaxis after implementation of fast-track surgery with early mobilization might be question ed . The fast-track group will therefore focus on a large ( n = 5,000 ) prospect i ve , detailed 90-day follow-up study with prophylaxis only until discharge ( 1–3 days ) . It is well-documented that cognitive function declines after THA and TKA in elderly patients ( Maze et al. 2008 ) . A fast-track setup may reduce cognitive dysfunction due to less postoperative sleep disturbances , less pain , and less opioid requirements , all of which may impair cognitive function . Finally , in the fast-track THA and TKA setting , safety aspects will be assessed regarding the risk of hip dislocation , and knee stiffness after TKA . In summary , despite major improvements in care and short-term outcome after THA and TKA , several issues remain to be answered in order to optimize fast-track treatment OBJECTIVE In elective large bowel surgery the incidence of general complications with st and ard perioperative care is up to 27 % . Hospital discharge occurs 10 to 15 days after a conventional or laparoscopic colonic resection . The aim of a fast track management is to reduce the number of general complications and the length of hospital stay . MATERIAL AND METHODS We prospect ively evaluated a multimodal protocol in our service utilizing a combined thoracic epidural analgesia , an early mobilization and oral nutrition to accelerate postoperative recovery after elective colonic surgery  . RESULTS One hundred thirty-two consecutive patients aged an average of 66 years ( range 22 - 88 ) were operated by laparotomy ( n = 71 ) or laparoscopy ( n = 61 ) and treated with the fast track rehabilitation protocol .  Surgical complications occurred in 15 patients ( 11 % ) , four of these had an anastomotique leakage ( 3 % ) . General complications occurred in 11 patients ( 8 % ) , the mortality was 1 % . The median length of hospital stay was four days ( range 3 - 77 ) and 14 patients ( 11 % ) had to be readmitted . CONCLUSION Application of a fast track rehabilitation protocol lowered the number of general complications and reduced the duration of hospital stay in our study Background Recent developments in large bowel surgery are the introduction of laparoscopic surgery and the implementation of multimodal fast track recovery programs . Both focus on a faster recovery and shorter hospital stay . The r and omized controlled multicenter LAFA-trial ( LAparoscopy and /or FAst track multimodal management versus st and ard care ) was conceived to determine whether laparoscopic surgery , fast track perioperative care or a combination of both is to be preferred over open surgery with st and ard care in patients having segmental colectomy for malignant disease . Methods / design The LAFA-trial is a double blinded , multicenter trial with a 2 × 2 balanced factorial design . Patients eligible for segmental colectomy for malignant colorectal disease i.e. right and left colectomy and anterior resection will be r and omized to either  open or laparoscopic colectomy  , and to either st and ard care or the fast track program . This factorial design produces four treatment groups ; open colectomy with st and ard care ( a ) , open colectomy with fast track program ( b ) , laparoscopic colectomy with st and ard care ( c ) , and laparoscopic surgery with fast track program ( d ) . Primary outcome parameter is postoperative hospital length of stay including readmission within 30 days . Secondary outcome parameters are quality of life two and four weeks after surgery , overall hospital costs , morbidity , patient satisfaction and readmission rate . Based on a mean postoperative hospital stay of 9 + /- 2.5 days a group size of 400 patients ( 100 each arm ) can reliably detect a minimum difference of 1 day between the four arms ( alfa = 0.95 , beta = 0.8 ) . With 100 patients in each arm a difference of 10 % in subscales of the Short Form 36 ( SF-36 ) question naire and social functioning can be detected . Discussion The LAFA-trial is a r and omized controlled multicenter trial that will provide evidence on the merits of fast track perioperative care and laparoscopic colorectal surgery in patients having segmental colectomy for malignant disease Background Fast-track surgery has been shown to enhance postoperative recovery in several surgical fields . This study aim ed to evaluate the safety and efficacy of fast-track surgery in laparoscopic distal gastrectomy . Methods The present study was design ed as a single-center , r and omized , unblinded , parallel-group trial . Patients were eligible if they had gastric cancer for which laparoscopic distal gastrectomy was indicated . The fast-track surgery protocol included intensive preoperative education , a short duration of fasting , a preoperative carbohydrate load , early postoperative ambulation , early feeding , and sufficient pain control using local anesthetics perfused via a local anesthesia pump device , with limited use of opioids . The primary endpoint was the duration of possible and actual postoperative hospital stay . Results We r and omized 47 patients into a fast-track group ( n = 22 ) and a conventional pathway group ( n = 22 ) , with three patients withdrawn . The possible and actual postoperative hospital stays were shorter in the fast-track group than in the conventional group ( 4.68 ± 0.65 vs. 7.05 ± 0.65 ; P < 0.001 and 5.36 ± 1.46 vs. 7.95 ± 1.98 ; P < 0.001 ) . The time to first flatus and pain intensity were not different between groups ; however , a greater frequency of additional pain control was needed in the conventional group ( 3.64 ± 3.66 vs. 1.64 ± 1.33 ; P = 0.023 ) . The fast-track group was superior to the conventional group in several factors of the European Organization for Research and Treatment of Cancer Quality of Life Question naire , including : fatigue , appetite loss , financial problems , and anxiety . The complication and readmission rates were similar between groups . Conclusions Fast-track surgery could enhance postoperative recovery , improve immediate postoperative quality of life , and be safely applied in laparoscopic distal gastrectomy In the attempt to reduce postoperative complications and costs and improve outcomes , the concept of fast track surgery has been proposed . Improvements in anesthesia techniques and a better underst and ing of the pathophysiologic events occurring during and after surgery have made it possible . A group of patients undergoing colorectal resections with a fast track approach were investigated ; specifically , the effects on postoperative morbidity , resumption of intestinal function , and duration of hospitalization .  Fifty patients were managed according to a protocol , which included epidural analgesia , early ambulation , and oral feeding ( fast track group ) ;  they were compared with 50 patients managed with a different protocol : no epidural analgesia , early ambulation , and early oral diet ( control group ) . Primary outcome end-points reported include morbidity , time to passage of flatus and stool , and length of hospital stay . Fourteen complications occurred in the fast track group and 13 in the control group ( P = not significant ( NS ) ) . Resumption of intestinal function occurred after 3 days , and length of hospital stay was 5 days in the fast track group compared with 4 and 7 days respectively in control patients ( P = NS , P < 0.01 ) . Patients undergoing elective colorectal resections can be managed safely with fast track protocol s reducing hospital stay BACKGROUND There is increasing interest in implementing comprehensive perioperative protocol s , including preoperative optimization and education , perioperative goal -directed fluid management , and postoperative fast tracking , to enhance recovery after surgery . Data on the outcomes of these protocol s in pancreatic surgery , however , are limited . STUDY DESIGN A retrospective review of a prospect ively maintained pancreas surgery data base at a single institution from August 2012 to April 2015 was undertaken . An enhanced recovery protocol was initiated in October 2014 , and patients were divided into groups according to pre protocol or post protocol implementation . Preoperative , intraoperative , and postoperative data were tabulated . Statistical analysis was performed with Student 's t-test and Fisher 's exact tests , as well as e quality of variances where appropriate , using SAS System software ( SAS Institute ) . RESULTS Three hundred and seventy-eight patients ( 181 men , mean age 54 years , BMI 28 kg/m(2 ) ) underwent elective pancreatic surgery during the study period , 297 patients pre protocol and 81 post protocol . There were no significant differences in preoperative or intraoperative characteristics . Mean postoperative length of stay was significantly lower in the Enhanced Recovery After Surgery group ( 7.4 vs 9.2 days ; p < 0.0001 ) . Hospital costs were similarly lower in the Enhanced Recovery After Surgery group ( $ 23,307.90 vs $ 27,387.80 ; p < 0.0001 ) . Readmission ( 29 % vs 32 % ) and pancreatic fistula ( 26 % vs 28 % ) rates were similar between groups . Delayed gastric emptying was lower in the Enhanced Recovery After Surgery group ( 26 % vs 13 % ; p = 0.03 ) . CONCLUSIONS Implementation of an enhanced recovery after pancreatic surgery protocol significantly decreased length of stay and hospital cost without increasing readmission or morbidity . Despite patient complexity and the potential need for individualization of care , enhanced recovery protocol s can be valuable and effective in high-risk patient population s , including pancreatic surgery patients BACKGROUND Evidence -based guidelines on optimal perioperative fluid management have not been established , and recent r and omized trials in major abdominal surgery suggest that large amounts of fluid may increase morbidity and hospital stay . However , no information is available on detailed functional outcomes or with fast-track surgery . Therefore , we investigated the effects of two regimens of intraoperative fluids with physiological recovery as the primary outcome measure after fast-track colonic surgery . METHODS In a double-blind study , 32 ASA I-III patients undergoing elective colonic surgery were r and omized to ' restrictive ' ( Group 1 ) or ' liberal ' ( Group 2 ) perioperative fluid administration .  Fluid algorithms were based on fixed rates of crystalloid infusions and a st and ardized volume of colloid .  Pulmonary function ( spirometry ) was the primary outcome measure , with secondary outcomes of exercise capacity ( submaximal exercise test ) , orthostatic tolerance , cardiovascular hormonal responses , postoperative ileus ( transit of radio-opaque markers ) , postoperative nocturnal hypoxaemia , and overall recovery within a well-defined multimodal , fast-track recovery programme . Hospital stay and complications were also noted . RESULTS ' Restrictive ' ( median 1640 ml , range 935 - 2250 ml ) compared with ' liberal ' fluid administration ( median 5050 ml , range 3563 - 8050 ml ) led to significant improvement in pulmonary function and postoperative hypoxaemia . In contrast , we found significantly reduced concentrations of cardiovascularly active hormones ( renin , aldosterone , and angiotensin II ) in Group 2 . The number of patients with complications was not significantly different between the groups [ 1 ( ' liberal ' group ) [ corrected ] vs 6 ( ' restrictive ' group ) [ corrected ] patients , P = 0.08 ] . CONCLUSIONS A ' restrictive ' [ corrected ] fluid regimen led to a transient improvement in pulmonary function and postoperative hypoxaemia but no other differences in all-over physiological recovery compared with a ' liberal ' [ corrected ] fluid regimen after fast-track colonic surgery . Since morbidity tended to be increased with the ' restrictive ' fluid regimen , future studies should focus on the effect of individualized ' goal -directed ' fluid administration strategies rather than fixed fluid amounts on postoperative outcome Objective : To facilitate the planning of perioperative care pathways , a fast-track failure prediction model has been developed in patients undergoing cardiac surgery . This study externally vali date d such a fast-track failure risk prediction model and determined the potential clinical consequences to ICU bed utilization . Design : Prospect i ve cohort study . Setting : Cardiothoracic Surgery Department and Intensive Care Unit of Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin , Hong Kong . Patients : The St. Mary ’s Hospital fast-track failure risk prediction model was applied to patients included in an adult cardiac surgery data base ( January 2006 to June 2011 ) . Interventions : The performance of the fast-track failure risk model was assessed by discrimination and calibration methods . The potential clinical consequences of applying the model on ICU bed utilization was assessed using a decision curve analysis . Measurements and Main Results : Of the 1,597 patients , 175 ( 11 % ) failed fast-track management . The final up date d model showed very good discrimination ( area under the receiver operating characteristic curve = 0.82 , 95 % confidence interval 0.78–0.86 ) and adequate calibration ( Hosmer – Lemeshow goodness-of-fit statistic , p = 0.80 ) . A decision curve analysis showed that if a threshold probability range of fast-track failure of 5 % to 20 % is used to determine who should be electively admitted to the ICU and who should be admitted to a fast-track recovery unit , it would lead to a substantial benefit ( 23%–67 % ) in terms of effective bed utilization , even after taking into account the negative consequences of unplanned admissions . Conclusions : As the performance of the final up date d fast-track failure model was very good , it can be used to estimate the predicted probability of fast-track failure on individual patients . The clinical consequence of applying the final model appears substantial with regard to the potential increase in effective ICU bed utilization Objective : To evaluate the effect of  laparoscopic or open colectomy with fast track or st and ard perioperative care on patient 's immune status and stress response after surgery . Methods : Patients with nonmetastasized colon cancer were r and omized to laparoscopic or open colectomy with fast track or st and ard care .  Blood sample s were taken preoperatively ( baseline ) , and 1 , 2 , 24 , and 72 hours after surgery . Systemic HLA-DR expression , C-reactive protein , interleukin-6 , growth hormone , prolactin , and cortisol were analyzed . Results : Nineteen patients were r and omized for laparoscopy and fast track care ( LFT ) , 23 for laparoscopy and st and ard care ( LS ) , 17 for open surgery and fast track care ( OFT ) , and 20 for open surgery and st and ard care ( OS ) . Patient characteristics were comparable . Mean HLA-DR was 74.8 in the LFT group , 67.1 in the LS group , 52.8 in the OFT group , and 40.7 in the OS group . Repeated- measures 2-way analysis of variance ( ANOVA ) showed this can be attributed to type of surgery and not aftercare ( P = 0.002 ) . Interleukin-6 levels were highest in the OS group . Repeated- measures 2-way ANOVA showed this can be attributed to type of surgery and not aftercare ( P = 0.001 ) . C-reactive protein levels were highest in the OS group . Following repeated- measures 2-way ANOVA , this can be attributed to type of surgery and not aftercare ( P = 0.022 ) . Growth hormone was lowest in the LFT group . Following repeated- measures 2-way ANOVA , this can be attributed to type of aftercare and not to type of surgery ( P = 0.033 ) . No differences between the groups were seen regarding prolactin or cortisol . No differences in ( infectious ) complication rates were observed between the groups . Conclusions : This r and omized trial showed that immune function of HLA-DR in patients undergoing laparoscopic surgery with fast track care remains highest . This can be attributed to type of surgery and not aftercare . These results may indicate a reason for the accelerated recovery of patients treated laparoscopically within a fast track program as described in the LAparoscopy and /or FAst track multimodal management versus st and ard care ( LAFA-Trial ) ( www.trialregister.nl , protocol NTR222 ) The aim of this prospect i ve cohort study was to identify the patient factors that predict postoperative deviation from each item of a fast-track colorectal surgery protocol ( FT ) and these factors ’ influences on postoperative outcomes . A total of 606 patients with colorectal pathology from 2005 to 2011 were analyzed to assess the relationships between patient factors , the outcome variables , and the items of the FT program . The median length of stay was 5 days , and readmission rate was 2.3 % . The morbidity rate was 26.7 % . Independent predictors of prolonged length of stay were older than 75 years of age , ASA grade 3 and 4 , and the presence of an ileostomy . Independent predictors of morbidity were age above 75 years old and ASA grade , whereas age was confirmed as an independent predictor of mortality . Male sex , age above 75 years old , and ASA 3 and 4 were identified as independent predictors of negative compliance to most of the postoperative FT items Background Few clinical studies or r and omized clinical trial results have reported the impact of fast-track surgery on human immunity . This study aim ed to investigate the clinical and immune impact of fast-track surgery in colorectal cancer patients undergoing elective open surgery . Methods A controlled r and omized clinical trial was conducted from November 2008 to January 2009 with a 1-month postdischarge follow-up . A total of 70 patients with colorectal carcinoma requiring colorectal resection were r and omized into two groups : a fast-track group ( 35 cases ) and a conventional care group ( 35 cases ) . All included patients underwent elective open colorectal resection with combined tracheal intubation and general anesthesia .  Clinical parameters and markers of immune function were evaluated in both groups postoperatively . Results In all , 62 patients completed the study : 32 in the fast-track group and 30 in the conventional care group . Our findings revealed a significantly shorter postoperative hospital stay and faster return of gastrointestinal function in patients undergoing fast-track rehabilitation . In addition , we found a quicker response of white blood cells in the fast-track group than in the conventional care group . We also found that blood levels of globulin , immunoglobulin G , and complement 4 on postoperative day 3 were higher in the fast-track group than in the conventional care group . Conclusions Fast-track surgery accelerates clinical recovery and improves postoperative immunity after elective open surgery for colorectal carcinoma
A pattern of consistent evolution in fast-track protocol s was clearly demonstrated and these have shown variations in the core-identified components across the studies .
In the future incremental gains through focused improvements in key components will lend itself to even better postoperative outcomes and patient experience during oesophageal cancer treatment
Fast track is a st and ardised goal directed patient 's care pathway that aims to facilitate recovery following surgery .
Currently , there are large variations in the fast track protocol s used in oesophagectomy due to the complexity of the procedure .
The objective of this systematic review is to assess the evolution of fast track protocol s  following oesophagectomy  since its implementation and the result ing effect on postoperative outcomes .