2. 94 Int J Colorectal Dis (2008) 23:93ā99
Keywords Colonic resection . Peri-operative treatment . Materials and methods
Multi-modal therapy . Morbidity . Hospital stay . Fast-track
Study design The quality assurance programme āFast-
trackā Colon II was designed as a prospective multi-
centre study. German hospitals with surgeons known to
Introduction
perform āFast-trackā rehabilitation as standard care in
Since the first multi-modal peri-operative clinical path- elective colonic surgery were invited to participate (see
way based on the best scientific evidence available was Appendix). Between March 2005 and October 2006, 25
published by Kehlet et al in 1995 [1], āFast-trackā hospitals of all sizes from small hospitals in rural parts of
rehabilitation or āERASā (āenhanced recovery after Germany to major university hospitals participated in the
surgeryā) was successfully adopted by several centres in quality assurance programme on a purely voluntary basis.
the UK, Scandinavia and Germany [1ā3]. All published Until October 2005, the total number of patients included
āFast-trackā rehabilitation series achieved the same into this study was 1,047. After informed consent, all
results: enhanced post-operative patient recovery, dimin- patients agreed to participate in this prospective study.
ished post-operative fatigue, prevention of post-operative
ileus and accelerated recovery with patients being dis- Peri-operative therapy Before hospitals were allowed to
charged from hospital within 2 to 5 days after surgery [1, enter patients into this study, the chairman of each
department provided detailed information on the āFast-
3ā6]. Most important, post-operative general morbidity
was reduced from more than 20% under ātraditionalā peri- trackā programme used. Information concerning peri-
operative care [7ā11] to 10% or less with āFast-trackā operative care was entered into a 15-page questionnaire
rehabilitation [1, 3ā7]. with 79 items covering pre-operative patient preparation,
Critics of āFast-trackā rehabilitation may argue that all operative technique in conventional and laparoscopic
reports of successful āFast-trackā programmes came from surgery, anaesthesia and analgesia, post-operative care,
major specialised units and that implementation in smaller hospital discharge and re-admission. All chairmen also
declared that āFast-trackā rehabilitation was the standard
or less specialised units may be difficult if not impossible.
To evaluate whether āFast-trackā rehabilitation for colonic peri-operative care programme in their department and
resection can be applied to an unselected patient population agreed to enter all patients undergoing elective colonic
outside of specialised centres, in 2005, a quality assurance surgery into the database. Details of the peri-operative
programme (QualitƤtssicherungsmaĆnahme āFast-trackā II- clinical āFast-trackā pathway for elective colonic resection
Kolon) was initiated in Germany. are given in Table 1.
Table 1 Protocol for peri-operative āFast-trackā rehabilitation in elective colonic surgery in the German Quality Assurance Programme āFast-
trackā Colon II
Time Procedure
Pre-operative Informed consent, discuss discharge on postoperative day 5-7 when feasible
Intra-operative Non-opioid analgesia after induction of anaesthesia; thoracic combined EDA (LA/opioid; level Th6āTh8),
transverse laparotomy when feasible, 5 trocar-laparoscopy or laparoscopic assisted procedure, avoid
intraperitoneal drains, extract nasogastric tube at extubation
Day of surgery Admit to regular nursing floor via PACU continuous EDA (LA/opioid), basal i.v. non-opioid analgesia, avoid
systemic opioids, limit post-operative i.v.-fluids to 500 cm3; drink 1,500 cm3, if orthostatic dysregulation
occurs add 500ā1,000 cm3 of crystalloids i.v, 2 protein drinks; magnesium oxide 3Ć300 mg per day until
first bowel movement; short walk outside of room, mobilized to chair for 2 h
Post-operative day 1 Continuous EDA (LA/opioid), avoid systemic opioids, basal oral non-opioid analgesia, regular hospital food,
drink >1,500 cm3; mobilized out of bed up to 8 h, walk outside of room twice; extract urinary catheter
Terminate EDA in the morning, basal i.v. non-opioid analgesia, regular hospital food, drink >1,500 cm3; fully
Post-operative day 2
mobilise
from post-operative day 3 Continue as on day 2, until patient is discharged
Post-operative day 8 (if already Outpatient clinic; extract skin staples; discuss result of histological examination, plan adjuvant therapy if
discharged) needed
EDA Epidural analgesia, LA local anaesthetics, PACU post-anaesthesia care unit, EDC epidural catheter, CVL central venous catheter
4. 96 Int J Colorectal Dis (2008) 23:93ā99
Table 2 Characteristics of
Characteristics Values
participating hospitals and in-
cluded patient in the prospec-
Hospitals (n=24)
tive observational quality
assurance programme āFast- Number Percent
University hospital 2 8
trackā Colon II
University affiliated teaching hospital 14 58
Non-academic hospital 8 33
Median Range
Number of surgical beds 75 34ā158
Number of patients included 41 3ā206
Patients (n=1,047)
Median Range
age (years) 66 20ā95
BMI (kg mā2) 26.0 15.4ā52.2
Number Percent
sex (female) 598 57.2
ASA class III/IV 354 33.8
Concomitant disease
Cardiac 498 47.7
Hypertension 363 34.7
Pulmonary 135 12.9
Diabetes mellitus 122 11.7
Renal 51 4.9
Hepatobiliary 21 2.0
Operative technique
Conventional 541 51.7
Laparoscopic 506 48.3
Indications for surgery
485a
Benign disease 46.4
562b
Tumour 53.6
Surgical procedure
Sigmoidectomy 552 52.7
Right hemicolectomy 219 20.9
a Left hemicolectomy 94 9.0
106 (21.8%) open and 379
Extended hemicolectomy (left or right) 53 5.1
(78.1%) laparoscopic resections
b
435 (77.4%) open and 127 Ileocecal resection 25 2.4
(22.6%) laparoscopic resections Other (i.e. segmental resection, bypass) 104 10.0
Table 3 Parameters of peri-
Peri-operative treatment parameter (n=1047)
operative treatment and
post-operative recovery after
Number Percent
āFast-trackā colonic resection
epidural analgesia 907 86.6
enforced mobilization Median Range
0ā2 h on post-operative day 0 0ā2
2ā8 h on post-operative day 1 0ā2
>8 h on post-operative day 2 1-2
Early oral feeding
Liquid food on post-operative day 0 0-7
Solid food on post-operative day 1 0-7
i.v. fluids until post-operative day 1 0-43
First post-operative bowel movement on post-operative day 2 0-11
Number Percent
Insertion of nasogastric tube post-operative? 52 5.0
Median Range
Discharge criteria fulfilled on post-operative day 5 1ā83
Discharged on post-operative day 8 1ā83
5. Int J Colorectal Dis (2008) 23:93ā99 97
Morbidity, mortality Local (surgical) morbidity was ob- epidural analgesia, early oral feeding and enforced mobi-
served in 148 patients (14.1%), with superficial wound lisation on the day of surgery. While post-operative local
morbidity was not increased (14.1%), āFast-trackā rehabili-
healing impairment being the most common local compli-
cation (n=67, 6.4%). Anastomotic leakage occurred in 29 tation achieved its main goal, to reduce the incidence of
general complications from more than 20% with ātraditionalā
patients (2.7%), and insertion of a nasogastric tube because
of prolonged gastrointestinal dysfunction was indicated in care [7ā11] to below 10% (9.1%).
53 patients (4.9%; Table 4). General morbidity was In Germany, Western Europe and the USA, peri-
diagnosed in only 95 patients (9.1%). Cardiac complication operative treatment of patients undergoing elective colonic
(n=32, 3.1%) was the most common general morbidity surgery is based on traditions rather than the best scientific
(Table 4). In the post-operative course, eight patients evidence available [12]. Repeated audits among German
(0.8%) died. Six deaths were related to local complications, surgeons demonstrated almost no change in peri-operative
while two patients died because of general morbidity only therapy within the last decade of the twentieth century [13].
(pulmonary embolism, myocardial infarction). Furthermore, financial stimuli to improve peri-operative
care with the aim of accelerated recovery and early
Post-operative hospital stay and rate of re-admission Pre- discharge from the hospital have not been initiated in
defined discharge criteria were met within 5 (1ā83) days Germany so far. In fact, under the rules and regulations of
after surgery, and patients were discharged after 8 (3ā83) the German DRG system, a hospital stay of less than 5ā7 days
days. Forty-one patients (3.9%) were re-admitted 14 (5ā35) for elective colonic resection will be punished by a reduced
days after discharge for surgical (n=25; 2.6%) and/or reimbursement to the hospital [14]. Given these facts, it
seemed very unlikely that āFast-trackā rehabilitation would be
medical (n=17; 1.8%) reasons.
introduced to German hospitals very fast.
Recently, two major quality assurance programmes in
Discussion Germany assessed the results of laparoscopic colorectal
surgery (Laparoscopic Colorectal Surgery Study Group,
This prospective multi-centre German quality assurance LCSSG [8, 15]) or conventional colorectal cancer surgery
programme shows that āFast-trackā rehabilitation is feasible (Working Group Colon/Rectum Carcinoma, WGCRC [7,
in an unselected group of patients admitted to elective 10]). Both quality assurance programmes were purely
colonic resection. Compliance with the āFast-trackā regimen voluntary and performed a prospective data acquisition
was high, with more than 85% of all patients receiving from patients undergoing colorectal surgery. There was no
Table 4 Local and general
Total (n=1,047)
morbidity, mortality after elec-
tive āFast-trackā rehabilitation
Number Percent
for elective colonic resection
Surgical complications
Patients 143 13.7
Incidents
Subcutaneous wound infection 67 6.4
Anastomotic leakage 29 2.8
Bleeding (re-operation) 21 2.0
Fascial dehiscence 11 1.1
Ileus (re-operation) 5 0.5
Small bowel lesion 2 0.3
General complications
Patients 95 9.1
Incidents
Cardiac 32 3.1
Pulmonary 27 2.6
Renal 20 1.9
Neurological/psychiatric 19 1.8
Urinary tract 14 1.4
Catheter related 3 0.3
Hepatic 3 0.3
Mortality 8 0.8
7. Int J Colorectal Dis (2008) 23:93ā99 99
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