Fast-Track Surgery: Information & Fast-Track Specialists

“Fast-Track Surgery = Surgery with a Fast Track => Rapid Recovery”

After abdominal surgery, there are a number of factors that influence the course of recovery. These include the surgeon’s skill, dexterity, and experience. Other factors that negatively impact the recovery process after surgery include:

• surgical stress,
• hypothermia during surgery,
• Nausea and vomiting after anesthesia and surgery,
• Bed rest,
• bowel paralysis (atony), or
• fasting before and after surgery (perioperative).

The goals of the fast-track approach are: 

• to preempt the negative effects of these factors,
• to minimize the trauma of surgery,
• to speed up the recovery phase,
• to restore the physical balance disrupted by surgery, and
• thereby maintaining and promoting the patient’s independence.

The Fast-Track concept begins well before surgery. Its most important component is providing the patient with detailed explanations and information. The patient must be informed about the surgery and the procedures for the days following it.

Until a few years ago, patients were prepared for surgery in a more or less technical manner. For example, it was standard practice to

• to flush out their intestines with several liters of fluid prior to a bowel resection.
• to fast for days before the procedure to protect the new bowel anastomosis.

As a result, patients were already under physical and psychological stress even before the surgery. This has a negative impact on the healing process.

For this reason, the approach has changed fundamentally in recent years. In the late 1990s, the Danish anesthesiologist H-Kehlet first described a concept of fast-track rehabilitation.

This concept revolutionized treatment before, during, and after bowel resection. It leads to a shorter recovery time for the patient. At the same time, it reduces the complications associated with the surgery.

Instead of a complete bowel irrigation, only an enema is used today for rectal surgeries. Instead of requiring several days of fasting—and the resulting fluid deficiency—even before surgery, a personalized approach is now taken. During the preoperative risk assessment, it is determined whether a patient is susceptible to this issue. If so, the patient can be prepared accordingly over the course of a few days.

All other patients are allowed to eat and drink up to six hours before surgery. They may still consume sweetened tea up to two hours before anesthesia begins.

An important component of the fast-track concept is tailored pain management. In addition to general anesthesia, each patient receives

• a preoperative epidural catheter (placed near the spinal cord) or
• a patient-controlled analgesia pump.

Through these devices, they can receive pain medication as needed during and after the operation.

The advantage of these systems is that they reduce the amount of pain medication required. This eliminates associated side effects such as bowel atony.

They also allow for faster patient mobilization. This reduces the risk of further complications, such as thrombosis.

Minimally invasive surgery with smaller abdominal incisions helps further reduce surgical stress.

The Fast-Track concept is also applied in surgeries that are not performed using minimally invasive techniques. Here, technical modifications (e.g., transverse, smaller abdominal incisions) minimize trauma.

Avoiding the use of drains, catheters, and nasogastric tubes after surgery contributes to a faster recovery.

Some changes occur without the patient noticing, such as

• targeted, fluid-controlled perioperative infusion therapy
• keeping the patient warm to prevent hypothermia during surgery.

The following also contribute to a better postoperative course (after surgery) and rapid rehabilitation

• early mobilization,
• feeding starting on the day of surgery,
• physical therapy, and
• close monitoring of pain levels

.

Discharge 4–5 days after a bowel resection is certainly possible. The average length of stay is 7–9 days. These durations are very short compared to those of recent years.

A key factor in a fast-track rehabilitation program is effective interdisciplinary collaboration between

• the surgeon,
• anesthesiologist, and
• nursing staff.

They must all act and make decisions in the best interest of the individual patient. However, this also requires a high level of commitment from everyone involved. This entails significant effort and places high demands on logistics and the allocation of resources.

Unfortunately, due to staffing shortages, a functional fast-track approach often fails because of these factors.

Below is a bullet-point summary of a fast-track approach using colon resection as an example.

Pre-hospitalization (before admission to the hospital):

• Pre-hospitalization preparation
• Risk assessment
• Discussion of the inpatient procedure
• Information material on the fast-track concept

Admission Day:

• Discussion about the inpatient process
• Informed Consent Form

Surgery date:

• Up to 2 hours before surgery: glucose drink
• Thoracic epidural catheter (PDK)
• Minimally invasive surgery / surgical approach (e.g., transverse)
• No drains
• Remove MS immediately postoperatively
• “Single-shot” antibiotics
• Continuous PDK
• Peripheral-systemic baseline analgesia
• Reduced infusion volume (max. 500 ml)
• Tea/water starting 4 hours after surgery
• Mobilization (getting up) starting 6 hours after surgery

First postoperative day:

• Continuous PDK
• Peripheral-systemic baseline analgesia
• Infusion volume (max. 500 ml)
• Yogurt, liquid nutrition (3 x 200 ml)
• Remove DK (if present)
• 3 x 2 g Mg++ orally (until the first bowel movement)
• 8 hours of out-of-bed mobilization
• Walk 3 times down the ward hallway

Second postoperative day:

• Remove PDK
• Peripheral analgesia 4 times daily
• Full mobilization
• Light meals

Third postoperative day:

• Removal of PDK
• Regular meal
• Social Services
• Nutrition counseling
• Discussion of progress/findings

Fourth postoperative day:

• Final surgical consultation
• Clarification of discharge criteria

Fifth postoperative day:

• Discharge possible

Ninth postoperative day:

• Outpatient follow-up examination
• Discussion of histology (lab results)
• Discussion of further treatment options

The Fast-Track concept has been shown to reduce postoperative complications and the length of hospital stay.

This also offers economic and financial incentives. A colon resection is billed according to the DRG (Diagnosis-Related Group) system. This means that health insurance companies set a kind of “fixed price.” Shortening the length of hospital stay can therefore save costs.

Reducing the complication rate saves additional associated costs. Furthermore, capacity is freed up sooner or is not needed at all. This makes it possible to treat more patients (and thus generate more DRGs) by increasing the number of cases.

Consequently, not only the patient but also the hospital can benefit from the fast-track concept.

Surgery is shaped in many areas by tradition and “tried-and-true” practices. Surgeons find it difficult to break with principles that have been consistently applied up to now and to explore new approaches.

The fast-track concept challenges some of the previously used and established approaches. However, engaging with it has led to a rapid shift toward a patient-centered mindset.

The Fast-Track concept is now increasingly accepted and applied as a clinical treatment pathway. However, the limited availability of resources often restricts the full implementation of the Fast-Track concept. We will have to wait and see how this develops.

For colon surgeries, the fast-track approach has now become a standard procedure. In addition, approaches are being developed for

• more complex gastrointestinal surgeries as well as
• thoracic surgery and
• vascular surgery

. There, too, they will help patients recover from surgery more quickly and safely.