No rushing under the knife
No rushing under the knife
Francesca Sacco

GENEVA — If the term “fast-track surgery” conjures a fast-food restaurant in your mind, then some explanation is in order. The term refers to a protocol that can reduce hospital stays by 30% to 50%, without any higher risk of readmission than ordinary surgery.

In a study published last June in the British Journal of Surgery, a University Hospital of Lausanne team confirmed that a patient who has undergone fast-track colon surgery can go home after three to five days, compared to 10 days with traditional care. And the rate of complications is almost twice as low as a result.

“Rapidity is not a goal in itself,” says Nicolas Demartines, head of the visceral surgery service at the University Hospital of Lausanne and co-author of the study. To avoid being likened with the term fast-food, doctors prefer to talk about “enhanced recovery after surgery.”

“The care is optimized as much as possible in the interest of the patient’s recovery,” Demartines says. The days when a patient had to fast before surgery, then put up with a gastric probe, a vesical probe and, finally, drains — and still wait for his intestines to start functioning again before he could eat normally — are over.

It all started around 1995 in Copenhagen, when Henrik Kehlet, professor at the University Hospital Rigshospitalet, demonstrated that the usual intestinal emptying before surgery was pointless. At the time, patients were required to stop eating at least eight hours before undergoing general anesthesia.

Kehlet proved that a three-hour abstinence is sufficient, and that fluids can be authorized up to two hours before surgery. In fact, it’s even recommended that pre-op patients have a drink high in carbohydrates — the kind that an athlete would have before a competition. “It’s about preparing the body to face important stress,” Demartines explains.

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University Hospital Rigshospitalet News Oresund

Kehlet also shot down another medical myth. “For a long time, we thought that after an operation, we had to sort of wait and see and not allow the patient to return to eating too quickly,” says Dr. Antoine Meyer of Fribourg Hospital, where the methodology was introduced in 2012. “We used to fear that it would provoke vomiting and, more importantly, that the stitches would rupture. But it turned out that this belief was groundless.”

“Liquid food can be offered to the patient without any restrictions the same day,” Demartines says. A German team from the University Hospital of Heidelberg even concluded that coffee is a positive intestinal stimulant for patients who have just undergone surgery.

Other fast-track measures

Fast-track surgery also includes several other practical measures — though not all are new — such as clearly informing patients before procedures so that they don’t go into surgery passively, minimal post-operative anesthesia, and warm blankets to help patients maintain body temperature. Finally, during recovery, patients are quickly urged to stand up and walk. Each of these steps was rethought and reexamined so as to favor early recovery.

To put these measures into practice, a multidisciplinary collaboration is necessary, implying, for instance, that a nutritionist, the doctor, the nurses, the anesthesiologist and a physiotherapist work hand in hand.

“The fast-track methodology is not a surgeon’s one-man show,” Demartines insists. “Experience shows that a partial adoption of the recommended measures leads to no benefits compared to traditional care. So we must follow all of them. But that makes it difficult to evaluate the impact of each of these methods.”

More generally, the fast-track methodology joins ambulatory care and minimally invasive surgery as part of the trend toward optimizing health care that has gained traction over the last few decades. For a few years now, it has been possible, for instance, to replace heart valves using a catheter, a long flexible tube that is inserted in the femoral artery and that enables delivery of a prosthetic valve to the heart, where it is implanted remotely. Thanks to that method, very old and weak patients who aren’t strong enough to withstand open-heart surgery can now be treated.

According to Demartines’ calculation, fast-track surgery saves each patient an average of $2,180 per operation. At the University Hospital of Lausanne alone, this represents $385,000 saved since 2011, when it became the first hospital in the country to adopt the method.

Patients who undergo fast-track surgery have shorter stays in the hospital and lower post-operative morbidity rates, says Sandrine Ostermann of the University Hospital of Geneva. This led a team of researchers from Duke University to say during a symposium organized last October in Durham, North Carolina, that this new methodology was “possibly one of the most important advances in surgery” in recent years.

In Switzerland, a dozen small and regional hospitals have followed in the footsteps of university centers. In the United Kingdom, fast-track surgery is now considered standard, and the state assumes a bigger share of the cost than it does with other methods, so as to promote it.

But “despite obvious scientific proof and impressive results, fast-track surgery is implemented only too slowly in clinical practice,” the Swiss journal Forum Médical concludes. At the moment, it’s being used in less than of third of Swiss surgeries, and mostly in digestive procedures, colon cancer operations or appendectomies. More recently, its use is becoming more widespread in urology, gynecology and orthopedics.

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