"Fast-track"-rehabilitation in surgery, a multimodal concept

Postoperative rehabilitation versus early mobilization following scoliosis surgery: A single-blind randomized clinical trial

BACKGROUND

To compare the effect of five days of intensive postoperative rehabilitation and early mobilization following scoliosis surgery.

METHODS

Forty adolescent patients who had undergone scoliosis surgery were randomly allocated into a rehabilitation group (RG, n = 20) and a mobilization group (MG, n = 20). The RG received five days of intensive exercise program and early ambulation, the MG received five days of a standard gait training and early ambulation. The patients were evaluated for severity of pain using a visual analog scale, thorax mobility with the thoracic mobility index, balance with the functional reach test, walking distance with the 2-min walk test, and quality of life with the Scoliosis Research Society-22 questionnaire. The length of hospital stay was recorded.

RESULTS

The RG was favored over the MG for improvements from 0 to 1 week for pain. Improvements from 0 to 1 week were significantly better in the RG than the MG group for thorax mobility, balance, and walking distance. Quality of life scores improvements from 0 to 1 week were significantly better in the RG group than in the MG group. The length of hospital stay was significantly shorter in the RG group.

CONCLUSION

Five days of intensive postoperative rehabilitation were superior to early mobilization in reducing the length of hospital stay, and in improving physical and functional outcomes following scoliosis surgery.

Enhanced Recovery After Cardiac Surgery: Where Do We Stand?

Purpose of Review

Enhanced recovery after surgery (ERAS) protocols are multimodal and multi-professional strategies to enhance postoperative convalescence and thereby reduce the length of hospital stay and hospital-associated complications. This review provides an up-to-date overview about basic principles of enhanced recovery after surgery protocols, their transfer into cardiac surgery, and their current state of evidence. It is supposed to offer clinical implications for further adaptations and implementations of such protocols in cardiac surgery.

Recent Findings

ERAS protocols are a story of success in numerous surgical disciplines and led to a paradigm shift in perioperative care and the establishment of ERAS Cardiac Society, a non-profit organization that provides evidence-based guidelines and recommendations for further development of enhanced recovery protocols, trying to harmonize the many existing efforts of individual approaches for cardiac surgery.

Summary

Promising results from comprehensive ERAS protocols in cardiac surgery emerged. Nevertheless, there is a paucity of high-quality data about holistic approaches in cardiac surgery and further efforts need to be promoted.

Perioperative Inpatient Opioid Consumption Following Autologous Free-Flap Breast Reconstruction Patients: An Examination of Risk and Patient-Reported Outcomes

BACKGROUND

The response to the unprecedented opioid crisis in the US has increased focus on multimodal pain regimens and enhanced recovery after surgery (ERAS) pathways to reduce opioid use. This study aimed to define patient and system-level factors related to perioperative consumption of opioids in autologous free-flap breast reconstruction.

METHODS

We conducted a retrospective study to identify patients who underwent autologous breast reconstruction between 2010 and 2016. A multivariate linear regression model was developed to assess patient and system-level factors influencing opioid consumption. Opioid consumption was then dichotomized as total postoperative opioid consumption above (high) and below (low) the 50th percentile to afford more in-depth interpretation of the regression analysis. Secondary outcome analyses examined postoperative complications and health-related quality-of-life outcomes using the BREAST-Q.

RESULTS

Overall, 601 patients were included in the analysis. Unilateral reconstruction, lower body mass index, older age, and administration of ketorolac and liposomal bupivacaine were associated with lower postoperative opioid consumption. In contrast, history of psychiatric diagnoses was associated with higher postoperative opioid consumption. There was no difference in the rates of postoperative complications when comparing the groups, although patients who had lower postoperative opioid consumption had higher BREAST-Q physical well-being scores.

CONCLUSION

System-level components of ERAS pathways may reduce opioid use following autologous breast reconstruction, but surgical and patient factors may increase opioid requirements in certain patients. ERAS programs including liposomal bupivacaine and ketorolac should be established on a system level in conjunction with continued focus on individualized care, particularly for patients at risk for high opioid consumption.

Is Enhanced Recovery the New Standard of Care in Microsurgical Breast Reconstruction?

BACKGROUND

At present, there are limited data available regarding the use and feasibility of enhanced recovery pathways for patients undergoing microsurgical breast reconstruction. The authors sought to assess patient outcomes before and after the introduction of an enhanced recovery pathway that was adopted at a single cancer center.

METHODS

A multidisciplinary enhanced recovery pathway was developed for patients undergoing deep inferior epigastric perforator or free transverse rectus abdominis myocutaneous flap breast reconstruction. Core elements of the enhanced recovery pathway included substituting intravenous patient-controlled analgesia with ketorolac and transversus abdominis plane blocks using liposomal bupivacaine, as well as intraoperative goal-directed fluid management. Patients who underwent surgery between April and August of 2015 using the enhanced recovery pathway were compared with a historical control cohort. The primary endpoints were hospital length of stay and total postoperative opioid consumption.

RESULTS

In total, 91 consecutive patients were analyzed (enhanced recovery pathway, n = 42; pre-enhanced recovery pathway, n = 49). Mean hospital length of stay was significantly shorter in the enhanced recovery pathway group than in the pre-enhanced recovery pathway group (4.0 days versus 5.0 days; p < 0.0001). Total postoperative morphine equivalent consumption was also lower in the enhanced recovery pathway group (46.0 mg versus 70.5 mg; p = 0.003). There was no difference in the incidence of 30-day complications between the groups (p = 0.6).

CONCLUSION

The adoption of an enhanced recovery pathway for deep inferior epigastric perforator and transverse rectus abdominis myocutaneous flap reconstruction by multiple surgeons significantly decreased opioid consumption and reduced length of stay by 1 day.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Enhanced recovery after elective colorectal resection outside a strict fast-track protocol. A single centre experience

INTRODUCTION

Optimising the management of hospitalised patients is a major concern. In colorectal surgery, the concept of enhanced recovery has been popularised by means of "fast-track" protocols, aiming at patient's discharge on the second postoperative day. Nevertheless, a strict fast-track protocol has several limitations. It is very demanding for the patient and therefore applicable only to a limited number of patients.

AIM

In order to optimise, in every aspect, the postoperative recovery of each patient undergoing an elective colorectal resection inside our institution, we set up a "soft" enhanced recovery programme.

MATERIAL-METHODS

A retrospective analysis was conducted in 92 patients evaluating the respective impact of protocol application throughout the duration of the hospital stay.

RESULTS

When all the required measures of our protocol were correctly implemented, the median discharge day was postoperative day 3 (range 3-5 days). On the contrary, when deviations occurred, they resulted in longer hospital stay (p < 0.001). Patients operated by laparoscopy were discharged earlier than patients operated by laparotomy (p < 0.001). The use of nasogastric tube and postoperative drainage prolonged significantly the length of stay (p = 0.001 and p < 0.001 respectively). When the urinary catheter was not removed or oral feeding not resumed on postoperative day 1, the patients were discharged later (p < 0.001).

CONCLUSIONS

There are substantial possibilities of optimising the recovery process after an elective colorectal resection, outside a strict fast-track protocol.

Selective Neurogenic Blockade and Perioperative Immune Reactivity in Patients Undergoing Lung Resection

OBJECTIVE: This double-blind, prospective, randomized, controlled trial examined the effects of thoracic epidural block and intravenous clonidine and opioid treatment on the postoperative Th1/Th2 cytokine ratio after lung surgery. The primary endpoint was the interferon γ (IFN-γ; Th1 cytokine)/interleukin 4 (IL-4; Th2 cytokine) ratio. Secondary endpoints were reductions in pain and incidence of pneumonia. METHODS: Sixty patients were randomized into three groups to receive remifentanil intravenously (remifentanil group, n = 20), remifentanil and clonidine intravenously (clonidine group, n = 20), or ropivacaine epidurally (ropivacaine group, n = 20). Pain was assessed using a numerical rating scale (NRS). Cytokines were measured using a cytometric bead array. RESULTS: Patients in the ropivacaine group (thoracic epidural block) had a significantly lower IFN-γ/IL-4 ratio at the end of surgery than those in the remifentanil group and clonidine group. There were no significant between-group differences in the IFN-γ/IL-4 ratio at other time-points. There were no differences in NRS scores at any time-point. No patient developed pneumonia. CONCLUSION: Intraoperative thoracic epidural block decreased the IFN-γ/IL-4 ratio immediately after lung surgery, indicating less inflammatory stimulation during surgery.

Enhanced recovery after colon surgery in a community hospital system

BACKGROUND

Enhanced recovery after colon surgery has not been widely adopted in the United States and Europe, despite evidence that postoperative complications and hospital length of stay are decreased.

OBJECTIVE

We sought to evaluate the introduction of a comprehensive care process for enhanced recovery after colon surgery in 8 community hospitals.

DESIGN

A system-wide, surgeon-directed, multidisciplinary committee developed a comprehensive enhanced-care quality-improvement program. Surgeons and operations leaders in each hospital developed the internal structure to implement the process.

PATIENTS

Surgeons had the option of entering or not entering patients in the enhanced-care pathway. Other than trauma patients, there were no exclusion criteria.

MAIN OUTCOME MEASURES

To limit selection bias, the study population included all patients undergoing colon resections (those entered and not entered in the care process). Length of stay, postoperative days, hospital costs, 30-day readmission rate, and return to surgery for the study population were compared with a 2-year historical baseline.

RESULTS

Forty-two percent of the study population was entered in the enhanced-care process. The average length of stay and the number of postoperative days in the study population decreased by 1.5 (P < .0001) and 1.3 (P < .0001) days. The rate of readmissions and returns to surgery remained stable (P > .05), and the average hospital cost decreased by $1763 (P = .02). Generalized linear regression analysis demonstrated that the enhanced-care process was a more significant variable than was the surgical approach (laparoscopic vs open surgery) in decreasing length of stay.

LIMITATIONS

The degree of compliance with care process elements and the relative contribution of each element of the care process are unknown.

CONCLUSIONS

A comprehensive enhanced-care colon surgery care process was successfully introduced in a community hospital system, as indicated by the clinical outcome measures.

Fast-track colorectal surgery program reduces hospital length of stay

PURPOSE

This study compared outcomes of a fast-track postoperative program implemented for patients undergoing laparoscopic colorectal surgery on 2 surgical units to patients receiving traditional postoperative care following laparoscopic colorectal surgery prior to implementation of the fast-track program.

AIMS

The primary aim was to determine if there was a significant difference in length of stay and 30-day readmission rates between the 2 groups. The secondary aim was to examine whether patients on the fast-track program were able to successfully tolerate early diet, early ambulation, and minimal use of drains.

SETTING

The study was conducted at a large Midwestern hospital.

METHOD

A retrospective medical record review was done on 100 patients who underwent laparoscopic colorectal surgery on the fast-track program for data pertaining to the research questions. Additionally, a medical record review was done for comparison on 100 matched controls based on age, sex, surgeon, and surgical procedure who received traditional postoperative care following laparoscopic colorectal surgery.

FINDINGS

A statistical significant difference of 1 day was found between patients receiving traditional care and patients on the fast-track program. Readmission rates between the 2 groups were not statistically significantly different.

CONCLUSION

: Overall, patients undergoing laparoscopic colorectal surgery on a fast-track program discharged 1 day sooner than patients on traditional recovery programs. Patients successfully followed the fast-track program.

IMPLICATIONS

Fast-track programs in colorectal surgery reduce length of stay and could be considered for other surgical populations.

Prehabilitation and early rehabilitation after spinal surgery: randomized clinical trial

OBJECTIVE

To evaluate the outcome after spinal surgery when adding prehabilitation to the early rehabilitation.

DESIGN

A randomized clinical study.

SETTING

Orthopaedic surgery department.

SUBJECT

Sixty patients scheduled for surgery followed by inpatient rehabilitation for degenerative lumbar disease.

INTERVENTIONS

The patients were computer randomized to prehabilitation and early rehabilitation (28 patients) or to standard care exclusively (32 patients). The intervention began two months prior to the operation. The prehabilitation included an intensive exercise programme and optimization of the analgesic treatment. Protein drinks were given the day before surgery. The early postoperative rehabilitation included balanced pain therapy with self-administered epidural analgesia, doubled intensified mobilization and protein supplements.

MAIN MEASURES

The outcome measurements were postoperative stay, complications, functionality, pain and satisfaction.

RESULTS

At operation the intervention group had improved function, assessed by Roland Morris Questionnaire (P = 0.001). After surgery the intervention group reached the recovery milestones faster than the control group (1-6 days versus 3-13, P =0.001), and left hospital earlier (5 (3-9) versus 7 (5-15) days, P =0.007). There was no difference in postoperative complications, adverse events, low back pain and radiating pain, timed up and go, sit-to-stand or in life quality. Patient satisfaction was significantly higher in the intervention group compared with the control group.

CONCLUSION

The integrated programme of prehabilitation and early rehabilitation improved the outcome and shortened the hospital stay - without more complications, pain or dissatisfaction.

Evidence-based surgical care and the evolution of fast-track surgery

BACKGROUND

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.

OBJECTIVE

To assess, synthesize, and discuss implementation of "fast-track" recovery programs.

DATA SOURCES

Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work.

DATA SYNTHESIS

Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology.

CONCLUSION

Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.

Readmission rates after a planned hospital stay of 2 versus 3 days in fast-track colonic surgery

Background

Initial programmes of fast-track open colonic surgery with a planned 2-day postoperative hospital stay have had a high readmission rate (about 20 per cent). The aim of this large, consecutive series was to compare readmission rates after a fast-track open colonic surgery programme with a planned hospital stay of 2 versus 3 days.

Methods

The study included 541 consecutive colonic resections from one surgical department with a structured care programme, including well defined discharge criteria, between April 1997 and December 2005. The planned hospital stay was increased from 2 to 3 days from August 2004. All patients were examined 8 and 30 days after surgery.

Results

Readmission rates fell from 20·1 per cent in 408 patients with a planned 2-day hospital stay (period 1) to 11·3 per cent in 133 patients with a planned 3-day hospital stay (period 2) (P &lt; 0·020). Median length of primary hospital stay was 2 and 3 days, median stay after readmission was 5 and 5·5 days, and median (mean) total stay was 3 (5·6) and 3 (5·7) days in periods 1 and 2 respectively. The readmission rate in period 2 was lower because there were fewer readmissions for short-term observation or social reasons. There was no difference in type and incidence of morbidity between the two periods.

Conclusion

Readmission after fast-track open colonic resection was reduced by planning discharge 3 instead of 2 days after surgery, with the same discharge criteria.