Ambulatory colectomy: fast-track management pushed to its limits?

Excerpt

Enhanced recovery after surgery provides patients with optimal means to counteract or minimize the deleterious effects of surgery [1‐3]. This concept can be adapted to suit colorectal procedures and comes in the form of a clinical pathway covering the pre-, per- and postoperative periods. Enhanced recovery after colorectal surgery includes preoperative, intraoperative, and postoperative measures and consists of a multidisciplinary approach involving surgeons, anesthesiologists, nurses, dieticians and physiotherapists. A French expert panel assessed the impact of parameters included in the fast-track programs on six foreseeable consequences of colorectal surgery; these were surgical stress, postoperative ileus, fluid and electrolyte imbalances, decreased postoperative mobility, sleep disorders, and postoperative complications. The experts validated the value of each parameter in terms of efficacy criteria for success of fast-track programs. After a review of the literature, 19 parameters were identified as potentially impacting at least one of the foreseeable consequences of colorectal surgery, namely the rate of postoperative complications and the duration of hospital stay. After synthesis of the work of experts on the 19 parameters using a well-defined methodology, the organizing committee reached 35 formal recommendations that were published as guidelines [4]. In a prospective randomized trial, Vlug et al. demonstrated that laparoscopy in combination with fast-track multimodal management was the best strategy over laparoscopy in a standard care or open surgery in either fast-track or standard care [5]. This particularly applies to colectomy or proctectomy for cancer [6]. …