Management of patients in fast track surgery

Abstract

Surgery is slowly undergoing revolutionary changes due to newer approaches to pain control, the introduction of techniques that reduce the perioperative stress response, and the use of minimally invasive operations. Subsequently, many surgical procedures (such as arthroscopic surgery, laparoscopic cholecystectomy, eye surgery, sterilisation procedures, herniorrhaphy, and cosmetic operations) are routinely performed on an outpatient basis. Recently published pilot studies suggest that when these newer approaches are used in patients undergoing more complex elective surgical procedures, postoperative complications can be reduced, length of hospital stay decreased, and time to recovery shortened. This review of recent advances made in this newly developing specialty of fast track surgery will emphasise techniques that facilitate early recovery after major surgical procedures. Fast track surgery combines various techniques used in the care of patients undergoing elective operations. The methods used include epidural or regional anaesthesia, minimally invasive techniques, optimal pain control, and aggressive postoperative rehabilitation, including early enteral (oral) nutrition and ambulation. The combination of these approaches reduces the stress response and organ dysfunction and therefore greatly shorten the time required for full recovery. Recent advances in understanding perioperative pathophysiology have indicated that multiple factors contribute to postoperative morbidity, length of stay in hospital, and convalescence (fig 1). Major improvements in surgical outcome may therefore require multifaceted interventions (fig 2). Ambulatory surgery has become routine for many procedures with a well documented record for safety and low morbidity, even in patients at high risk. 1 2 Studies of fast track surgery have evaluated somewhat similar approaches toward larger operations which carry more risk (box). Preliminary results from predominantly non-randomised trials have been positive (table). These studies have included high risk elderly patients undergoing operations such as segmental colonic resection, prostatectomy, and aortic aneurysmectomy. These preliminary data indicate topics for further randomised trials; the data need to …