Top

World Journal of Surgery

Published in:

01-03-2009

A Prospective Randomized Trial Comparing Traditional and Fast-Track Patient Care in Elective Open Infrarenal Aneurysm Repair

Authors: Bernd Muehling, Hubert Schelzig, Peter Steffen, Rainer Meierhenrich, Ludger Sunder-Plassmann, Karl-Heinz Orend

Published in: World Journal of Surgery | Issue 3/2009

Abstract

Background

Fast-track recovery programs have led to reduced patient morbidity and mortality after major surgery. In terms of elective open infrarenal aneurysm repair, no evidence is available about such programs. To address this issue, we have conducted a randomized prospective pilot study.

Methods

The study involved prospective randomization of 101 patients with the indication for elective open aneurysm repair in a traditional and a fast-track treatment arm. The basic fast-track elements were no bowel preparation, reduced preoperative fasting, patient-controlled epidural analgesia (PCEA), enhanced postoperative feeding, and postoperative mobilization. Morbidity and mortality, need for postoperative mechanical ventilation, length of stay (LOS) in the intensive care unit (ICU) and total length of postoperative hospital stay were analyzed in terms of an intention to treat.

Results

Demographic data for the two groups were similar. In the fast-track group the need for postoperative ventilation was significantly lower (6.1% versus 32%; p = 0.002), the median LOS on ICU did not significantly differ (20 h versus 32 h; p = 0.183), full enteral feeding was achieved significantly earlier (5 versus 7 days; p < 0.0001), and the rate of postoperative medical complications—gastrointestinal, cardiac, pulmonary, renal, and infective—was significantly lower (16% versus 36%; p = 0.039). The postoperative hospital stay was significantly shorter in the fast-track group (10 days versus 11 days; p = 0.016); the mortality rate in both groups was 0%.

Conclusions

An optimized patient care program in open infrarenal aortic aneurysm repair shows favorable results concerning need for postoperative assisted mechanical ventilation, time to full enteral feeding, and incidence of medical complications. Further ranomized multicentric trials are necessary to justify broad implementation (clinical trials. gov identifier NCT 00615888).

Prinssen M, Verhoeven EL, Buth J, The Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group et al (2004) A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 351:1607–1618PubMedCrossRef

Greenhalgh RM, Brown LC, Kwong GP, The EVAR trial participants et al (2004) Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 364:843–848PubMedCrossRef

Ligush J Jr, Pearce JD, Edwards MS et al (2002) Analysis of medical risk factors and outcomes in patients undergoing open versus endovascular abdominal aortic aneurysm repair. J Vasc Surg 36:492–499PubMedCrossRef

Schermerhorn ML, O’Malley AJ, Jhaveri A et al (2008) Endovascular vs. open repair of abdominal aortic aneurysms in the Medicare population. N Engl J Med 358:464–474PubMedCrossRef

Brady AR, Fowkes FG, Greenhalgh RM et al (2000) Risk factors for postoperative death following elective surgical repair of abdominal aortic aneurysm: results from the UK Small Aneurysm Trial. On behalf of the UK Small Aneurysm Trial participants. Br J Surg 87:742–749PubMedCrossRef

Tang T, Walsh SR, Fanshawe TR et al (2007) Estimation of physiologic ability and surgical stress (E-PASS) as a predictor of immediate outcome after elective abdominal aortic aneurysm surgery. Am J Surg 194:176–182PubMedCrossRef

Hertzer NR, Mascha EJ, Karafa MT et al (2002) Open infrarenal abdominal aortic aneurysm repair: the Cleveland Clinic experience from 1989 to 1998. J Vasc Surg 35:1145–1154PubMedCrossRef

Fearon KC, Ljungqvist O, Von Meyenfeldt M et al (2005) Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 24:466–477 (Review)PubMedCrossRef

Kehlet H, Wilmore DW (2002) Multimodal strategies to improve surgical outcome. Am J Surg 183:630–641 (Review)PubMedCrossRef

10.

Anderson AD, McNaught CE, MacFie J et al (2003) Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg 90:1497–1504PubMedCrossRef

11.

Gatt M, Anderson AD, Reddy BS et al (2005) Randomized clinical trial of multimodal optimization of surgical care in patients undergoing major colonic resection. Br J Surg 92:1354–1362PubMedCrossRef

12.

Podore PC, Throop EB (1999) Infrarenal aortic surgery with a 3-day hospital stay: a report on success with a clinical pathway. J Vasc Surg 29:787–792PubMedCrossRef

13.

Murphy MA, Richards T, Atkinson C et al (2007) Fast track open aortic surgery: reduced post operative stay with a goal directed pathway. Eur J Vasc Endovasc Surg 34:274–278PubMedCrossRef

14.

Bellomo R, Ronco C, Kellum JA, The Acute Dialysis Quality Initiative Workgroup et al (2004) Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 8:R204–R212 (Review)PubMedCrossRef

15.

Torsello G, Can A, Schumacher S (2005) Das Bauchaortenaneurysma. Gefäßchirurgie 10:139–153CrossRef

16.

Wilmore DW, Kehlet H (2001) Management of patients in fast track surgery. BMJ 322:473–476PubMedCrossRef

17.

Basse L, Raskov HH, Hjort Jakobsen D et al (2002) Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. Br J Surg 89:446–453PubMedCrossRef

18.

Wind J, Polle SW, Fung Kon Jin PH, The Laparoscopy and/or Fast Track Multimodal Management Versus Standard Care (LAFA) Study Group; Enhanced Recovery after Surgery (ERAS) Group et al (2006) Systematic review of enhanced recovery programmes in colonic surgery. Br J Surg 93:800–809 (Review)PubMedCrossRef

19.

Becquemin JP, Chemla E, Chatellier G et al (2000) Preoperative factors influencing the outcome of elective abdominal aorta aneurysm repair. Eur J Vasc Endovasc Surg 20:84–89PubMedCrossRef

20.

Harris PL, Vallabhaneni SR, Desgranges P et al (2000) Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm repair. J Vasc Surg 32:739–749PubMedCrossRef

21.

22.

Svanfeldt M, Thorell A, Hausel J et al (2005) Effect of “preoperative” oral carbohydrate treatment on insulin action—a randomised cross-over unblinded study in healthy subjects. Clin Nutr 24:815–821PubMedCrossRef

23.

Frank SM, Fleisher LA, Breslow MJ et al (1997) Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 277:1127–1134PubMedCrossRef

24.

Bown MJ, Nicholson ML, Bell PR et al (2003) The systemic inflammatory response syndrome, organ failure, and mortality after abdominal aortic aneurysm repair. J Vasc Surg 37:600–606PubMedCrossRef

25.

Liu S, Carpenter RL, Neal JM (1995) Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology 82:1474–1506 (Review)PubMedCrossRef

26.

Kirnö K, Friberg P, Grzegorczyk A et al (1994) Thoracic epidural anesthesia during coronary artery bypass surgery: effects on cardiac sympathetic activity, myocardial blood flow and metabolism, and central hemodynamics. Anesth Analg 79:1075–1081PubMed

27.

Kehlet H, Holte K (2002) Epidural anaesthesia and analgesia in major surgery. Lancet 360:568–569 author reply 569PubMedCrossRef

28.

Ballantyne JC, Carr DB, deFerranti S et al (1998) The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 86:598–612PubMedCrossRef

29.

Umscheid T, Eckstein HH, Noppeney T et al (2000) Qualitätsmanagement Bauchaortenaneurysma er Deutschen Gesellschaft für Gefäßchirurgie (DGG)—Ergebnisse. Gefäßchirurgie 6:194–200CrossRef

30.

Bastounis E, Filis K, Georgopoulos S et al (2003) Selective use of the intensive care unit after elective infrarenal abdominal aortic aneurysm repair. Int Angiol 22:308–316PubMed

31.

Han-Geurts IJ, Hop WC, Kok NF et al (2007) Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery. Br J Surg 94:555–561PubMedCrossRef

32.

Cambria RP, Brewster DC, Abbott WM et al (1990) Transperitoneal versus retroperitoneal approach for aortic reconstruction: a randomized prospective study. J Vasc Surg 11:314–324 discussion 324–325PubMedCrossRef

Title: A Prospective Randomized Trial Comparing Traditional and Fast-Track Patient Care in Elective Open Infrarenal Aneurysm Repair
Authors: Bernd Muehling
Hubert Schelzig
Peter Steffen
Rainer Meierhenrich
Ludger Sunder-Plassmann
Karl-Heinz Orend
Publication date: 01-03-2009
Publisher: Springer-Verlag
Published in: World Journal of Surgery / Issue 3/2009
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-008-9892-2

At a glance: The STEP trials

Springer Medicine

A Prospective Randomized Trial Comparing Traditional and Fast-Track Patient Care in Elective Open Infrarenal Aneurysm Repair

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 3/2009

Localization of Recurrent Thyroid Cancer Using Intraoperative Ultrasound-Guided Dye Injection

Design and Implementation of a Web-Based System for Intraoperative Consultation

Laparoscopic Surgical Skills Assessment: Can Simulators Replace Experts?

Selective Nonoperative Management of Kidney Gunshot Injuries

Prognostic Factors of Pulmonary Metastasectomy for Colorectal Carcinomas

Surgery Resident Education 1986–2008: Effort, Respect, and Advocacy