Fast-track surgery: information & fast-track specialists

Aims of fast-track surgery

"Fast-track surgery = surgery of the fast track => fast recovery"

After abdominal surgery, there are a number of factors that influence the course of an operation. These include the skill, ability and experience of the surgeon. Other factors that have a negative impact on the outcome of an operation are

• Surgical stress,
• Hypothermia during the operation,
• nausea and vomiting after anesthesia and surgery,
• bed rest,
• intestinal paralysis (atony) or
• fasting before and after the operation (perioperative).

The aims of the fast-track concept are to

• to prevent the negative effects of these factors
• to minimize the trauma of the operation
• to accelerate the recovery phase,
• to restore the physical balance disturbed by the operation and
• to maintain and promote the patient's independence.

The fast-track concept begins well before an operation. The most important part of this is providing the patient with detailed information. The patient must know about the operation and the procedures on the following days.

History of the fast-track concept

Until a few years ago, patients were more or less technically prepared for surgery. It was standard practice to

• flush the bowel clean with several liters of fluid before a bowel resection.
• Patients were instructed to fast for days before the operation in order to protect the new intestinal connection.

As a result, the patient was already physically and mentally stressed before the operation. This has a negative effect on the healing process.

For this reason, the approach has changed fundamentally in recent times. At the end of the 1990s, the Danish anesthetist H-Kehlet first described the concept of fast-track rehabilitation.

The concept revolutionized treatment before, during and after bowel resection. It leads to an improvement in the patient's recovery time. At the same time, it reduces the complications associated with the operation.

Instead of a complete bowel lavage, only an enema is used for rectal surgery today. Instead of several days of fasting and the associated lack of fluids before the operation, an individualized approach is now used. During the risk assessment before the operation, it becomes clear whether a patient is susceptible to this. They can then be prepared for a few days if necessary.

All other patients may eat and drink up to six hours before the operation. They may drink sweetened tea up to two hours before the start of anesthesia.

Differentiated pain therapy as part of fast-track surgery

An important component of the fast-track concept is differentiated pain therapy. In addition to general anesthesia, every patient receives

• a preoperatively applied catheter close to the spinal cord (epidural catheter) or
• a patient-controlled pain pump.

These systems can be used to administer painkillers as required during and after the operation.

The advantage of these systems is the reduction in the amount of pain medication. This eliminates associated side effects such as intestinal atony.

They also allow the patient to be mobilized more quickly. This reduces the risk of further complications, such as thrombosis.

Part of the fast-track concept is early mobilization of the patient © New Africa | AdobeStock

Fast-track concept for minimally invasive and non-minimally invasive surgery

Minimally invasive surgery with smaller abdominal incisions contributes to a further reduction in surgical stress.

The fast-track concept is also used for non-minimally invasive operations. Here, technical changes (e.g. transverse, smaller abdominal incisions) minimize trauma.

The elimination of drains and catheters as well as the gastric tube after the operation contribute to a faster recovery.

Other components of the fast-track concept

Some changes go unnoticed by the patient, such as

• Targeted and fluid-controlled perioperative infusion therapy
• warming the patient to prevent hypothermia during the operation.

A better postoperative course (after the operation) and rapid rehabilitation are also helped by

• rapid mobilization,
• nutrition starting on the day of the operation,
• physiotherapeutic care and
• close monitoring of the pain situation

contribute to this.

Discharges after 4-5 days following bowel resection are quite possible. The average length of stay is 7-9 days. These times are very low compared to the lengths of stay in recent years.

Good interdisciplinary cooperation between the following is important for a fast-track rehabilitation concept

• surgeon,
• anaesthetist and
• nursing service.

They all have to act and make decisions in the interests of the individual patient. However, this also means a high level of commitment from everyone involved. This involves a great deal of effort and high demands on logistics and the commitment of resources.

Unfortunately, a functioning fast-track concept often fails due to the tight staffing situation.

Treatment pathway for a fast-track colon resection

Below you will find a fast-track concept using the example of a colon resection.

Pre-inpatient (before admission to hospital):

• Pre-hospital preparation
• Risk assessment
• Discussion about the inpatient procedure
• Fast-track concept information material

Admission day:

• Discussion about inpatient procedure
• Declaration of consent

Day of surgery:

• Glucose drink up to 2 hours before the operation
• Thoracic epidural catheter (PDK)
• Minimally invasive surgery / surgical access route (e.g. transverse)
• No drainage tubes
• Remove MS directly postoperatively
• Antibiotics "single shot"
• Continuous PDK
• Peripheral-systemic basic analgesia
• Reduced infusion volume (max. 500ml)
• Tea/water from the 4th hour after surgery
• Mobilization (getting up) from the 6th hour after the operation

First postoperative day:

• Continuous PDK
• Peripheral-systemic basic analgesia
• Infusion volume (max. 500ml)
• Yoghurt, liquid nutrition (3 x 200ml)
• DK removal (if available)
• 3x 2g Mg++ orally (until 1st bowel movement)
• Mobilization 8h outside the bed
• 3 x walk across the ward corridor

Second postoperative day:

• Unplug PDK
• Peripheral analgesia 4 x daily
• Complete mobilization
• Light diet

Third postoperative day:

• Removal of PDK
• Full diet meal
• Social services
• Nutritional counseling
• Discussion about progress/findings

Fourth postoperative day:

• Final surgical consultation
• Clarification of discharge criteria

Fifth postoperative day:

• Discharge possible

Ninth postoperative day:

• Outpatient check-up
• Discussion of histology (laboratory values)
• Discussion about further forms of therapy

Cost-benefit analysis of the fast-track concept

The fast-track concept has been proven to reduce postoperative complications and the length of inpatient stays.

This also offers financial incentives. A colon resection is billed according to the DRG system (Diagnosis Related Group). This means that the health insurance companies specify a kind of "fixed price". Costs can therefore be saved by shortening the length of hospital stay.

Reducing the complication rate saves further associated costs. In addition, capacities are freed up earlier or are not required. This makes it possible to treat more patients (and thus DRGs) by increasing the number of cases.

This means that not only the patient but also the hospital can benefit from the fast-track concept.

Summary and outlook for the fast-track concept

In many areas, surgery is characterized by tradition and "tried and tested" procedures. Surgeons find it difficult to break with principles that have been consistently applied to date and to break new ground.

The fast-track concept influences some of the previously used and proven concepts. However, dealing with this has led to a rapid patient-oriented rethink.

The fast-track concept is now increasingly being accepted and applied as a clinical treatment pathway. However, the level of available resources often restricts the full implementation of the fast-track concept. Further developments will have to be awaited.

The fast-track concept is now a standard procedure for operations on the colon. In addition, concepts for

• more complex gastrointestinal operations as well as
• chestsurgery (thoracic surgery) and vascular surgery
• in vascular surgery

are being developed. They will also help patients to get through the procedure more quickly and safely.