Fast Track Pathways in Colorectal Surgery: Rinaldy Teja Setiawan

Fast Track
Pathways in
Colorectal
Surgery
Rinaldy Teja Setiawan

Introduction
– Fast Track Pathways, also known as ERAS pathways (first introduce in the mid 1990)
– Addition to the care of patients undergoing colorectal procedures.
– The purpose :
– Minimizing surgical pain and enhancing recovery
– Leading to fewer complications
– More rapid hospital discharge
– Improved overall outcomes
– Several small trials have been performed in the past several years comparing traditional perioperative management with
a fast track pathways approach in colorectal surgery.
– These studies demonstrated :
– More rapid return of bowel function
– Shorter inpatient hospital stays
– Fewer complications.
– At least 2 studies noted an increased rate of readmissions after fast track
surgery.
– Systematic review and meta – analysis has supported
– These findings with decreased hospital; stay and no change in mortality,
complications, or readmissions.
– From this information, fast track protocols are a safe useful tool for any surgeon
performing colorectal procedures.
Preoperative Evaluation and
Patient Selection
– The best candidates for fast track protocol are Primarily Healthy Individuals
Requiring straightforward procedures for Diverticulitis, polyps, or
nonobstructive
– Any patient with ASA 1 or 2 and select ASA 3 patients may be included.
– In ideal circumstances, the protocol should be discussed with the patient in a
preoperative clinic visit, and the goals, advantages and risks discussed in detail
– There are also several patient groups in which fast track management is
inadvisable :
– Malnourished
– Immobile / minimal mobile
– Patient with requiring emergent procedures (ischemia, obstruction, or perforation)
Indication and Contraindication to Fast
Track Management in Colorectal Surgery
Bowel Preparation
– Mechanical bowel preparation before elective colorectal surgery was previously

considered the standard of care for decades
– It was thought to decreased infectious complications and anastomotic
dehiscence by decreasing intraluminal fecal mass and bacterial load.
– Cathartic bowel preparation may cause dehydration and potentially severe
electrolyte toxicities, especially in elderly patients with renal insufficiency and
should not be treated lightly.
– Meta-analyses of multiple trials have concluded that bowel preparation for
patient unnecessary and fails to decrease infectious complications or improve
outcomes after colorectal surgery.
Continue
– Current clinical practice guideline from the Canadian Society of Colon and Rectal
Surgeons endorses omitting bowel preparation for open left sided and right sided
colon surgery but has found insufficient evidence for patient undergoing
laparoscopic or low anterior resection procedures.
– Some surgeons may also prefer to use a bowel preparation in all laparoscopic
procedures to make colon manipulation easier, and guidelines published bythe
Society of Alimentary Gastrointestinal Endoscopic Surgeons (SAGES) have endorsed
the use of bowel preparations in laparoscopic colorectal surgery.
– At the present there is no study specifically investigating the use of cathartic bowel
preparation in a fast – track pathway, although soime studies investigating fast track
protocols omitted bowel preparation . Whereas included a strandard bowel
preparation.
Laparoscopic VS Open
Procedures
– Laparoscopy has revolutionized the modern practice of surgery and has become a standard method for
performing colon resection. Properly performed laparoscopic colon surgery achieves appriopriate surgical
margins, accurate staging, and equivalent survival when compared with open surgery.
– A meta-anaylises of long term outcomes comparing laparoscopi to open colorectal surgery for cancer resection
found no difference In Tumor Recurrence, Cancer – Related mortality, as well as reoperations for hernia or
adhesions.
– There is no difference in reoperation rate or postoperative complications with laparoscopic or open surgery
approach.
– Several advantages of laparoscopic approach :
– less post operative pain,
– fewer wound infections,
– shorter time to return of bowel function,
– shorter hospital stay.
– For these reason, a laparoscopic approach should be preferred in the
establishment of a fast – track pathway.
– Thus, although the laparoscpic approach will likely yield more rapid return to
normal activity and hospital discharge, an open surgery approach should not
exclusively preclude inclusion in a fast – track protocol
Fluid Management
– Excess intravenous (IV) fluid is suspected :

– Increase interstitial volume and total body weight
– Leading to ambulation difficulty
– Cardiopulmonary dysfunction
– Impaired tissue oxygenation
• These effects are suspected to contribute to Anastomotic breakdown and wound infection
• Two trials of patients undergoing colorectal surgery comparing “standard” and “restricted” fluid
administration found fewer complications in fluid restriction patients.
• But, in fluid - restricted patients had less hypoxia and improved pulmonary function.
– Standard perioperative fluid management is divided into intraoperative and
postoperative periods.
– Intraoperatively, insensible fluid losses are replaced 2ml/kg/h and third space losses
are replaced 1 – 3 ml/kg/h for minor surgical trauma (hernia repair, etc) up to 6 to 8
ml/kg/h for major surgical trauma (colon resection procedures,etc)
– In patient receiving bowel preparations, this deficit may be even greater
– Blood loss is replaced 3 ml of chrystalloid for every 1 ml of blood lost
– Post op, maintenance fluid is administered at 4 ml/kg/h for the first 10 kg of body
weight, 2 ml/kg/h for the next 10 kg, and 1 ml/kg/h for each kg beyond 20 kg.
– Vital sign are monitored, with urine output goal of 0.5 – 1 ml/kg/h
– Owing to the differences in fuid administration in different trials. Meta-analysis defined “standard” fluid
management using calcutlated estimates of fluid requirements based on the patient weight, enght and
type of procedure.
– A ranged was defined as the mean value +10% , “restriction” > 10% beneath the low limit of this range, “excess”
>10% above the upper limit.
– This study failed to find any significant differences in mortality, anastomotic leakage, or wound infection,
but overall morbidity was decreased when intraoperative fluids were restricted.
– Decreases in morbidity were also found in patients using intraoperative esophageal Dopple – guided fluid
management, although this method is experimental and not in widespread use.
Pain Management
– controlled opioid analgesia (PCA) technique or indwelling continuous epidural

analgesia (CEA) with opiod or local anesthesia infusion for pain control.
– PCA has the benefit of providing systemic delivery of opioids, which acts on
opiate receptors in the brain and body, and yields immediate pain relief.
– disadvantages include systemic opioid effects including respiratory depression,
sedation, nausea and vomiting, and prolongation of postoperative ileus.
– CEA, also known as neuraxial anesthesia, has the benefit of delivering a combination of local
and opioid analgesia directly to the dorsal horn of the spinal cord, thus delivering pain relief
without systemic opioid effects. Negative side effects  pruritis, urinary retention, and
arterial hypotension, often necessitating additional fluid administration.
– CEA may be used safely in conjunction with pharmacologic deep venous thrombosis (DVT)
prophylaxis, and practice guidelines for proper use are available from the American Society of
Regional Anesthesia.Several trials have investigated the potential benefits of PCA and CEA in
patients undergoing colorectal surgery with regard to pain control, resumption of diet,
resolution of ileus, and hospital discharge.
– Most trials have found a benefit with CEA for the end points pain control, diet resumption,
and ileus resolution but have failed to demonstrate a decrease in hospital stay.
– Superiority of CEA seems to be greatest in the first 2 to 3 postoperative days
(PODs), so routine removal of CEA after POD 2 or 3 may be a useful strategy in a
fast-track pathway.If not anticipated, waiting for catheter removal could actually
delay discharge by an additional day, thereby nullifying any benefit achieved by
earlier resumption of diet and resolution of ileus.
– Other modalities of pain control include local control by wound infiltration with
local anesthesia.
– NSAIDs  ibuprofen / ketorolac
– Ketorolac  immediate postoperative period. It acts through prostaglandin
inhibition and has a similar time to onset as IV morphine but has longer
duration (6–8 h) and minimal central nervous system effects of respiratory
depression, sedation, nausea, and vomiting. Side effects  inhibition of platelet
aggregation, gastrointestinal (GI) ulceration, and renal toxicity and so should be
avoided or used cautiously in patients with increased risk of bleeding or renal
dysfunction.
– Acetaminophen  adjunct to oral narcotic pain medication.
DIET ADVANCEMENT
– should have a functional nonobstructed GI tract immediately before their colorectal

procedure.
– Gastric drainage tubes have been shown to increase pulmonary complications, delay bowel
function, and increase length of stay without any difference in anastomotic breakdown and so
should not be used without evidence of ileus or obstruction.
– Early enteral feeding has been studied extensively, and Chestovich et al multiple trials and a
meta-analysis have shown it to be safe and possibly beneficial for patient recovery from
colorectal surgery. Most fast-track protocols allow at least some liquids immediately after
surgery, some with addition of protein shakes for added nutrition.
– The addition of alvimopan (Entereg), a highly selective m-receptor antagonist, has been
shown to improve recovery of intestinal function without adversely affecting postoperative
analgesia and may be useful in a fast-track protocol.
DRAINAGE
– Anastomotic drainage is a long-standing controversial topic, and many studies

have been conducted investigating its merits.
– Meta-analyses of trials in this topic have failed to show a benefit for routine
drainage, and routine anastomotic drainage is not typically part of a fast-track
pathway.
– However, if clinically indicated, drain placement should not interfere with a
standard fast-track protocol.
READMISSIONS
– Readmission after discharge after colorectal surgery has been a significant drawback to
adoption of fast-track pathways.
– Several studies comparing fast-track to conventional pathways have demonstrated higher
readmission rates for patients in the fast-track group when compared with the conventional
group.
– Importantly, despite the increased readmissions, the total hospital days are still lower for
patients managed by fast-track pathways.
– However, a slightly higher readmission rate should be anticipated when adopting a fast-track
protocol.
– notify patients of this preoperatively and verify that patients are reliable, have good social
support structure, and are able to return to the hospital should concerns or complications
arise.
SCIP MEASURES
– SCIP is a widely publicized initiative by the Center for Medicare and Medicaid
Services (CMS) and Centers for Disease Control (CDC) to reduce the number of
postoperative complications.  include surgical site infections (SSI), adverse cardiac
events, DVT and thromboembolism, and postoperative pneumonia.
– SSI prevention—Appropriate hair clipping, appropriate antibiotic administration
within 1 hour before skin incision and discontinued within 24 hours, and immediate
postoperative normothermia (T >98.6F within 1 hour of leaving operating room).
Adverse cardiac events—Patients on preoperative beta-blockade should be
continued throughout the operation and perioperative period. DVT—Appropriate
thromboembolism prophylaxis (low-dose unfractionated heparin 5000 units twice
or thrice daily or low-molecular-weight heparin combined with intermittent
pneumatic compression or graduated compression stockings)
PROTOCOL MODIFICATIONS
– No perioperative management protocol is perfect for all patients.

– simply meant to act as a framework to standardize the postoperative
management, minimize complications, and decrease hospital stays, and
protocol deviations are expected.
– Each patient should be closely followed throughout his or her hospitalization,
and protocol changes should be made for proper clinical indications.
– The fast-track protocol should not usurp good clinical judgment.
SUMMARY
–   streamline perioperative management for patients undergoing colorectal

surgery, decrease complications, reduce hospital resource use, and improve the
overall quality of care.
– careful patient selection and preoperative planning, avoidance of bowel
preparation, avoidance of excessive fluid, laparoscopic approach to surgery,
multimodal pain management, early ambulation, and rapid diet advancement.
– Despite the faster return to normal function and discharge, a higher
readmission rate is expected, although the overall hospital days are still fewer
than with standard management techniques.
REFERENCES

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Fast Track

Rinaldy Teja Setiawan

– Mechanical bowel preparation before elective colorectal surgery was previously

– Excess intravenous (IV) fluid is suspected :

– controlled opioid analgesia (PCA) technique or indwelling continuous epidural

– should have a functional nonobstructed GI tract immediately before their colorectal

– Anastomotic drainage is a long-standing controversial topic, and many studies

– No perioperative management protocol is perfect for all patients.

–   streamline perioperative management for patients undergoing colorectal

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