In this issue of BJOG Borendal Wodlin et al.1 report a randomised controlled trial (RCT) on the impact of mode of anaesthesia on postoperative recovery in a ‘fast-track’ setting. The authors describe several key elements of the ‘fast-track’ model of care. These include the avoidance of sedative pre-medication, pre-emptive antiemetic treatment, intravenous fluid restriction postoperatively, early enteral nutrition and mobilisation, and criteria-led discharge. In this study, young women (<60 years of age) undergoing surgery for benign indications were randomised to receive either spinal or general anaesthesia. The study was powered to show a reduction of 1 day in length of stay following spinal anaesthesia over the historic length of stay. During the study, the length of stay for both arms was 46–50 hours, with approximately 11% staying longer than 3 days. The authors conclude that there was no difference in length of stay between the two groups. However, using the ‘fast-track’ approach allowed patients in both arms of the study to meet the criteria required for safe discharge from hospital more quickly. In summary, this paper shows that applying the principles of ‘fast-track’ surgery leads to quicker postoperative recovery, with patients meeting discharge criteria being allowed safe discharge to home, with a concomitant reduction in length of stay, regardless of the type of anaesthesia used.
The approach—known variously as ‘fast-track’, ‘rapid’ or ‘accelerated’ recovery—was pioneered and evaluated in Denmark in the 1990s in colorectal surgery.2 In England this approach to surgery is being implemented through the Enhanced Recovery Partnership Programme of the Department of Health. There are four elements to the Enhanced Recovery Programme (ERP):
- 1 Preoperative assessement, planning and preparation before admission.
- 2Reducing the physiological stress of the operation.
- 3A structured approach to peri- and postoperative management.
- 4Early mobilisation.
Although the ERP is a novel and unifying approach to elective surgery, many of the elements of the programme will already be familiar and established practice in many UK hospitals. Other elements, such as preoperative carbohydrate loading, may not. Successful implementation of an ERP requires that patients are involved in decisions regarding their care (with patient information provided before admission), that they have a preoperative assessment, leading to the optimisation of their general condition before treatment, have the most appropriate peri-operative care (which reduces the physiological stress of surgery), and experience optimal postoperative rehabilitation.3 In addition, this approach leads to better staff engagement and satisfaction.4
The importance of preparation for surgery, and optimisation of pre-existing conditions, is well accepted. A recent publication by the Association of Anaesthetists of Great Britain and Ireland provides an excellent summary of this area of care.5 In many areas of England, social support for patients following discharge from hospital can only be arranged when patients are fit for discharge, and this can lead to delays in discharging patients back to the community. The ERPs encourage a more holistic approach, with consideration preoperatively of the social support that patients may need following discharge. In many areas, dialogue between all of the services providing care for the patient is beginning earlier, so that some elements of discharge planning can begin preoperatively.
There is no evidence to support the traditional practice of prolonged preoperative fasting, which was advocated in order to reduce the incidence of pulmonary aspiration.6 ERPs encourage patients to avoid solid foods for 6 hours prior to surgery, and to drink clear fluids up to 2 hours before surgery. In addition, the use of complex carbohydrate drinks up to two hours before surgery reduces the stress-related response of starving, avoiding insulin resistance and catabolism, thereby allowing quicker recovery.7
Recovery may be facilitated by employing a minimal access approach: vaginal hysterectomy confers advantages in benign gynaecology over other routes,8 and laparoscopic hysterectomy for uterine cancer is associated with less complications and a shorter hospital stay in comparison with abdominal surgery.9 Obviously, not all conditions are suitable for laparoscopic surgery, and individual consideration should be given to both the size and position of surgical incisions. The use of regional anaesthesia in the form of appropriately placed epidural has been regarded as the ‘gold standard’ for postoperative analgesia.3,10 However, the paper published in this issue of BJOG found that regional anaesthesia did not confer any advantages over general anaesthesia in terms of length of stay, although the requirement for opiate analgesia was reduced.1 Moreover, alternative forms of regional anaesthetic block, such as the transverse abdominis plane block, have been proposed, as well as the use of catheters allowing the prolonged administration of local anaesthesia.11
Minimally invasive cardiac output monitoring during surgery can be performed using transoesophageal Doppler probes or lithium dilutional techniques. These techniques can be used to guide intravascular fluid replacement during surgery more accurately, thus optimising perioperative organ perfusion. This technique has been shown to reduce postoperative morbidity and length of stay.12,13 The use of prophylactic antibiotics and prophylaxis for reducing venous thromboembolic disease are all well accepted. It is also important to avoid hypothermia, as this increases the postoperative complication rate.14 There is little benefit to the use of drains (nasogastric, abdominal or vaginal), and these contribute to morbidity, prolonged hospital stay and cost.15,16 Postoperatively, early feeding and mobilisation are important parts of the programme. Early feeding in major gynaecological surgery is safe and leads to shorter hospital stay.17 This feeding can start in the recovery room. Mobilisation of the patients in the early postoperative period is important, and requires an integrated approach with the patient, surgeon, nursing staff and physiotherapists. Appropriate analgesia and adequate staffing are also important elements to this success.
Patients discharged home as part of ERPs should have their continuing care needs in place as part of the programme. Patients are given contact details should advice or guidance be required in the first week following discharge. Models vary, but include 24-hour telephone advice from the hospital ward, and telephone follow-up at 1, 3 or 7 days following discharge. Using data from the USA, where there was a median length of stay of 2 days in a gynaecological oncology practice, it is possible that significant bed day savings could be made if this approach were applied across the UK.18 A Cochrane analysis shows no randomised evidence either supporting or refuting the enhanced recovery care pathway in gynaecological cancer care, and calls for further research in this area.19
So far ERPs (http://www.dh.gov.uk/enhancedrecovery) have been applied to patients undergoing colorectal, orthopaedic, urological and gynaecological procedures. It is anticipated that the approach can be extended to all forms of medical care, both elective and emergency, including obstetrics. It is anticipated that delivery of this programme of care, supported by the quality, innovation, productivity and prevention (QIPP) agenda and the professional bodies, will become the standard of care across all surgical specialties over the next 18 months. However, more evidence in the form of RCTs such as the one published here in BJOG,1 is needed in obstetric and gynaecological surgery to quantify better the benefits of ERPs to patients and health services compared with traditional approaches to surgical management.