In 1999, Henrik Kehlet, a Danish abdominal surgeon, discovered that effective analgesia after open sigmoidectomy could speed up patient recovery and pioneered the concept of fast-track surgery (FTS) in 2001. In the past ten years, FTS has been enriched and developed with great achievements.
I. The concept of rapid rehabilitation surgery
FTS also known as postoperative recovery (enhanced recovery aftersurgery, ERAS), refers to the use of a series of perioperative optimization measures proven effective by evidence-based medicine to reduce surgical stress, accelerate postoperative recovery. Stress refers to the neurological, endocrine and environmental changes caused by physical or chemical damage to the body or emotional factors.
There are many factors affecting stress, including: pain, nausea and vomiting, intestinal paralysis, insomnia and fatigue, catabolic and immune system disorders, etc. FTS uses existing tools to improve, optimize and combine various conventional treatment measures in the perioperative period, aiming to reduce surgical stress, maintain the stability of the patient’s internal environment, accelerate postoperative recovery and shorten the hospital stay.
II. Composition of rapid rehabilitation surgery
1, the establishment of “recovery team”: FTS is the use of multidisciplinary techniques to adopt a multiform intervention. Communication and cooperation among surgeons, anesthesiologists, nurses and physical therapists is the key to the success of FTS, and this cooperation should be carried out throughout the treatment. The “rehabilitation team” conducts preoperative assessments and improves patient status (e.g., nutrition, cardiopulmonary function, etc.), and subsequently develops a rapid recovery plan. During and after surgery, the “rehabilitation team” also makes adjustments to the plan according to the patient’s status.
Patient communication: Since some of the perioperative management of FTS is very different from traditional methods, it is necessary to inform patients and their families of the perioperative treatment plan. It can help to reduce the patient’s fear and anxiety and make the patient better cooperate with the medical staff.
Minimally invasive surgery: The use of minimally invasive surgical techniques such as laparoscopic techniques, comprehensive bloodless surgical field techniques and Ligsure vascular closure system can avoid the stressful reactions caused by “innocent” surgical injuries, reduce systemic inflammatory reactions and postoperative pain, and speed up postoperative recovery.
4. Simplification of routine bowel preparation before surgery: Mechanical bowel preparation before colorectal resection has been considered an effective means of preventing postoperative infection and anastomotic leak, but it is not recommended by FTS. 2009 Cochrane systematic review of 4777 cases found that the incidence of anastomotic leak in the preoperative bowel preparation group vs. no preparation group was 4.2% vs. 3.4%, and the incidence of postoperative infection was 9.6% vs. 8.3%. The rate of postoperative infection was 9.6% vs. 8.3%, and bowel preparation was not beneficial.
5. Optimization of anesthesia and postoperative analgesia.
①The choice of surgical anesthesia directly affects the patient’s postoperative recovery. General anesthesia generally selects drugs with fast onset, easy control of anesthetic depth and fast awakening, such as desflurane and sevoflurane for inhalation anesthesia, isoproterenol and etomidate for intravenous anesthesia. Local nerve block reduces protein loss due to endocrine catabolic response. The technique of continuous epidural block anesthesia is considered the most effective method to reduce postoperative intestinal paralysis, and the FTS recommends its use in intestinal surgery.
② Intraoperative hypothermia is defined as a central body temperature <36°C. Lower operating room temperature, intravenous fluids, blood transfusion, skin disinfection and anesthesia can all lower the patient's body temperature. Hypothermia can increase intraoperative bleeding, induce postoperative incisional infection, coagulation disorders, myocardial ischemia and prolong the action time of anesthetic drugs. Therefore, it is especially important to maintain a normal intraoperative body temperature. In recent years, some studies have proposed the idea of "perioperative system insulation", that is, preoperative and 2h postoperative insulation measures can significantly reduce postoperative complications.
③Effective postoperative analgesia is beneficial for patients to get out of bed early, oral feeding and recovery of organ function, and reduce stress reactions. However, excessive reliance on opioid analgesia in the postoperative period can lead to acute opioid tolerance, nociceptive sensitization and dose-dependent side effects such as pulmonary hyperventilation, nausea and vomiting, urinary retention and intestinal paralysis. Recent studies have focused more on non-opioid analgesia, and the effects and safety of non-steroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors, ketamine and postoperative local anesthetic techniques have been affirmed by numerous studies.
6. Perioperative nutritional management.
(1) Long-term preoperative fasting is not required. Traditional surgery requires patients to fast from midnight before surgery to prevent lung aspiration caused by tracheal intubation during anesthesia. It was found that drinking 800ml of 12.5% carbohydrate drink the night before surgery and 400ml 2-3h before surgery not only improves preoperative thirst, hunger and irritability, reduces the incidence of postoperative insulin resistance and surgically induced catabolism, and does not increase pulmonary misaspiration during anesthesia.
②FTS encourages patients to eat by mouth early after surgery. This is due to the reasonable postoperative analgesia and effective relief of nausea, vomiting and intestinal paralysis by FTS. Coehrane systematic review confirmed that normal oral feeding within 24h after gastroschisisis and colorectal resection is safe and feasible, which facilitates recovery of gastrointestinal function and reduces high catabolism, and complications such as anastomotic leakage are not increased.
③Infusion management: the composition and dosage of perioperative infusion are still controversial. An increasing number of studies have shown that. Excessive fluid infusion delays recovery of gastrointestinal function and increases postoperative complications and length of hospital stay. However, excessive fluid restriction can also cause functional hypovolemia and delay postoperative recovery.
Recently, there has been widespread interest in “goal-directed fluidtherapy”, which involves individualized rehydration by controlling the amount of fluid administered according to the optimal volume of heartbeats measured by esophageal Doppler or other methods. Randomized controlled trials have shown that this method can effectively relieve postoperative nausea and vomiting, intestinal paralysis, reduce anastomotic complications and hospital stay, and is especially suitable for high-risk patients.
7, control of nausea, vomiting and intestinal paralysis: the incidence of post-surgical nausea and vomiting is as high as 30%. Prophylactic application of antiemetic drugs, local anesthetic techniques and perioperative fluid management, without the use of opioid analgesics and other measures can relieve nausea and vomiting. It is important to emphasize that integrated control by multiple routes is more effective than a single route. Intestinal paralysis is an important cause of delayed postoperative recovery.
The most effective way to relieve intestinal paralysis is the technique of continuous epidural block anesthesia. The use of postoperative peripheral morphine receptor antagonists and laxatives, the non-routine use of nasogastric tubes and the prevention of fluid overload can also result in a significant reduction in the duration of postoperative intestinal paralysis. Recent randomized controlled trials and systematic reviews have confirmed that chewing gum reduces the duration of intestinal paralysis by 21 to 30 h without increasing postoperative complications. In view of its simplicity, effectiveness, safety and low price, it is recommended for routine use in postoperative abdominal surgery.
8. Rational use of drainage tubes: Evidence-based medical evidence shows that the non-use of nasogastric tubes after abdominal surgery can promote the recovery of intestinal function, reduce pulmonary complications, and not increase the incidence of anastomotic leakage, and patients feel more comfortable. With the exception of esophageal surgery, the routine use of nasogastric tubes is generally not advocated for abdominal surgery. Routine use of drainage tubes is not necessary for colorectal resection, gastrectomy, uncomplicated hepatectomy and open and laparoscopic cholecystectomy, thyroidectomy, and hip or knee replacement.
Catheters should also be removed 24 to 48 h after surgery. Although the short-term use of various drains does not cause complications, it restricts postoperative bed activity, delays the recovery of eating time and psychological state, and increases surgical stress, so various drains should be carefully selected or not routinely used.
9. Early postoperative bed activity: FTS encourages patients to be in pain-free condition. The patient can get out of bed on the 1st postoperative day. Early bed activity can prevent venous thrombosis and pulmonary infection, relieve postoperative fatigue and sleep disorders, and facilitate gastrointestinal function and mental and psychological recovery.
Third, the rapid rehabilitation surgery brings us to think
The concept of FTS was first applied to cardiac surgery, and now it has been extended to all fields of surgery. The most successful application of FTS is colorectal resection, and FTS can promote the recovery of postoperative intestinal obstruction, 90% of patients can eat and defecate normally within 48h after surgery, and the hospitalization time is shortened from 5-10 days to 2-4 days. However, the advantages of FTS have not been widely recognized and practiced by the global surgical community.
A 2009 survey of 461 surgical centers in Australia and Germany showed that the majority of patients still routinely underwent bowel preparation before surgery (Australia, 91%; Germany, 94%). There are also many questions about FTS: shorter hospital stays may increase the workload of healthcare professionals, lead to higher return rates, and patients may be discharged with more serious complications. Therefore, while FTS brings us hope, it also leaves us with infinite thoughts.
1. The inevitability of the emergence and development of FTS.
①The wide spread of evidence-based medical concepts has led to the questioning of some traditional medical methods: can the method really play a therapeutic role? Can it meet the expectations of patients and families for treatment?
(2) Medical and economic pressures have led to a reduction in hospitalization time, treatment costs and workload of medical and nursing staff, and an increase in bed turnover and utilization of medical resources;
(3) The medical model has changed from a purely biological model to a biopsychosocial model, so that the interests of patients dominate all medical activities, and the emergence of FTS is a reflection of this change.
2. Analysis of the reasons for the slow promotion of FTS in the world may be.
(1) Clinicians are not aware of or do not agree with the evidence-based medicine of FTS.
② Clinicians’ personal skills or related departmental skills have not yet met the requirements for implementing FTS.
(iii) Some of the measures of FTS are not yet supported by evidence-based medical evidence.
Although recent evidence suggests that patients scheduled for discharge on postoperative day 3 after colon cancer resection can maintain a re-hospitalization rate above normal levels. The development of FTS is still emerging, but clinicians should view FTS rationally and objectively.
Before applying FTS technology, they should fully consider the patient’s status and individual differences, the physician’s skill level and the hospital’s resources to ensure the smooth implementation of FTS, and should not make a big mistake by blindly pursuing shorter hospital stays. In addition, FTS is not limited to the above mentioned treatments. As long as the patient’s perioperative long-term and near-term outcomes are not less than or better than those of conventional treatment, any measures to promote rapid recovery should fall within the scope of FTS.
Also, FTS is not limited to the treatment of certain specific diseases; any surgical disease can be treated with appropriate FTS measures when conditions permit. Currently, FTS is also being attempted in some major surgeries, such as pancreaticoduodenectomy, liver resection and even liver transplantation. Therefore, FTS concepts and principles are more relevant than a specific measure of FTS.