Langenbecks Arch Surg (2006) 391:495–498
DOI 10.1007/s00423-006-0087-8
NEW SURGICAL HORIZONS
Future perspectives and research initiatives
in fast-track surgery
Henrik Kehlet
Received: 12 June 2006 / Accepted: 22 June 2006 / Published online: 19 August 2006
# Springer-Verlag 2006
Abstract
Background and aims Major surgery is still followed by a
risk of morbidity, a need for hospitalisation and convales-
cence. Fast-track surgery has been introduced as a
coordinated effort to combine unimodal evidence-based
principles of care into a multi-modal effort to enhance
recovery. The aim of this article was to update recent data
on fast-track abdominal surgery and outline future strate-
gies for research.
Results The data from fast-track colonic resection support
the validity of the concept because pain, ileus, cardiopul-
monary function and muscle function were all improved,
compared with traditional treatment and with reduced post-
operative fatigue and convalescence. Although less data is
available, similar positive results may be achieved in other
types of major surgery. Current research initiatives include
improved multi-modal non-opioid analgesia, rational prin-
ciples for perioperative fluid management, pharmacological
reduction of surgical stress responses and the role of
laparoscopic procedures within the fast-track concept.
Conclusions Fast-track surgery has evolved as a valid
concept to improve post-operative outcome. Further prog-
ress may be expected based upon intensified research
within perioperative pathophysiology and a multi-disciplin-
ary collaboration between surgeons, anaesthesiologists and
surgical nurses.
Keywords Fast-track surgery . Post-operative pain .
Fluids . Ileus . Surgical stress . Laparoscopic surgery
H. Kehlet (*)
Section for Surgical Pathophysiology, the Juliane Marie Centre,
4074, Rigshospitalet,
2100 Copenhagen, Denmark
e-mail: henrik.kehlet@rh.dk
Introduction
During the last 10 years, significant positive results have
been obtained to improve post-operative outcome as a
result of advantages within anaesthesia, pain control and the
use of minimal invasive surgery, based upon a better
understanding of perioperative pathophysiology. An effort
to combine these advantages together with a revision of
other perioperative care principles according to available
scientific evidence has been named “fast-track surgery” [1,
2], which has led to even more significant advantages than
single-modality interventions. Thus, the post-operative
recovery of organ functions has been enhanced, thereby
reducing morbidity and the need for post-operative hospi-
talisation and convalescence [1, 2] (Kehlet and Wilmore,
submitted). The benefits of fast-track surgery, modified for
procedure-specific characteristics, have been demonstrated
in almost every surgical speciality, with some examples
shown in Fig. 1 [1, 2] (Kehlet and Wilmore, submitted).
The present paper summarises recent data from fast-
tracking in major abdominal surgery, with specific attention
to aspects of perioperative care where current research
initiatives are taken, as well as suggestions for future
research, and organisational initiatives of fast-track surgery
are proposed.
Fast-track colorectal surgery
The initial reports on fast-track open colonic resection
reported a hospital stay of 2–3 days with conventional
discharge criteria. Subsequently, several studies, including a
few randomised studies, have been published from many
institutions and countries, confirming that hospital stay can
be decreased from about 8–12 days to 3–4 days [3]. The
496
lumbar disc op
thyroidectomy
arthroscop. op bariatric surg
mastectomy carotid endart.
parathyroid op. nephrectomy
adrenalectomy pulm. resection
cholecystectomy open hysterectomy
fundoplication rad. prostatectomy
lap/vag hyst. knee replacement aortic aneurism
hernia repair hip replacement colonic resection
ambulatory 1 – 2 days 2 – 3 days
Fig. 1 Hospital stay from recent studies of fast-track surgery (adapted
from Kehlet and Dahl [2] and Kehlet and Wilmore, submitted)
overall results have demonstrated enhanced early restora-
tion of organ functions including paralytic ileus, cardiopul-
monary exercise capacity and muscle force and improved
convalescense [3, 4]. A drawback as reported from the
initial centre in Copenhagen was a readmission rate of about
20%, but other centres have consistently reported readmis-
sion rates around 10%. This has also been achieved recently
in Copenhagen by altering the planned discharge from about
48 to 72 h post-operatively (Andersen et al., submitted).
These observations suggest that, despite the early achieve-
ment of conventional discharge criteria, it is advisable to
prolong the stay slightly, thus reducing readmissions due to
the need for observation, social issues, etc.
Although some fast-track data have been reported in
more complex colorectal procedures [5], there is a need for
more data on what can be achieved in fast-track rectal
surgery. Also, there is a lack of data from acute colorectal
procedures, where the benefits of the principles of fast-track
surgery may be even more pronounced.
Other major abdominal surgeries
In other major abdominal procedures there are few data, but
positive results using the same multi-modal principles of
care have been reported in oesophagectomy [6–8], abdom-
inal aortic aneurysm surgery [9], and outpatient laparo-
scopic gastric bypass for severe obesity [10].
Current research topics
Post-operative pain
Optimal post-operative pain relief is a well-documented
prerequisite for early recovery [2], and modern principles of
treatment include multi-modal analgesia, i.e. the use of
drugs or techniques that approach the pain pathway at
Langenbecks Arch Surg (2006) 391:495–498
different sites from the surgical incision to the spinal cord
and brain and with different types of analgesics [11]. For
the clinician, a public web site is available for a variety of
procedures (http://www.postoppain.org) [12] summarising
procedure-specific scientific evidence for optimal analgesia
based on randomised trials. For major abdominal surgery,
the use of continuous thoracic epidural analgesia with local
anaesthetics and a small dose of opioid remains a
cornerstone, supplemented by non-opioid analgesics if not
entirely sufficient. All efforts should be made to provide
opioid-reduced analgesia [13], and current research efforts
strive to combine several agents where each of them has
been demonstrated to provide analgesia together with
opioid sparing. Such agents include NSAIDs, COX-2
inhibitors, paracetamol, ketamine, gabapentin, glucocorti-
coids, systemic lidocaine, etc. [13]. Future research should
investigate whether multi-modal combinations can enhance
analgesic efficacy and stress reduction, thereby potentially
avoiding the present need for epidural analgesia.
Post-operative ileus
The obligatory paralytic ileus also remains a key factor to
control to increase patient comfort and allow early oral
nutrition, which otherwise has been demonstrated to reduce
morbidity. Current techniques include opioid-reduced anal-
gesia, continuous thoracic epidural analgesia with local
anaesthetics (the most effective technique), no use of
nasogastric tubes, avoidance of fluid excess, use of laxatives
(only demonstrated to be effective in gynaecological
surgery), early oral feeding and laparoscopic surgery [14,
15]. More recently, the use of a peripherally acting opioid
antagonist (Alvimopan) has been demonstrated in three
phase-III studies to reduce ileus after colonic surge [14],
and hopefully will be available for clinical use in late 2006
or early 2007. However, for conventional colorectal
surgery, ileus has repeatedly been demonstrated to be
reduced to less than 48 h in most patients using a
combination of the above-mentioned principles [3, 14, 15].
Further research is needed in major upper abdominal
procedures and in abdominal emergency cases, where no
data are available at present.
Fluid management
Traditionally, perioperative fluid management has been
rather liberal since the Korean War, but recently, several
studies have shown that a post-operative fluid excess may
have detrimental effects on recovery of the cardiopulmo-
nary system, paralytic ileus, and the coagulatory–fibrino-
lytic system [16, 17]. Unfortunately, most data come from
patient series with traditional care principles, but the few
blinded randomised studies with fast-track cholecystectomy
Langenbecks Arch Surg (2006) 391:495–498
[17] and colonic resection (Holte et al., unpublished)
suggest that procedure-specific principles of fluid manage-
ment are crucial to enhance recovery, including preopera-
tive optimisation/compensation for dehydration and
avoiding post-operative fluid excess. More recently, several
randomised trials have demonstrated a pronounced reduc-
tion of morbidity and hospital stay in major abdominal
surgery by the so-called “goal-directed fluid therapy”,
which represents an individually based preoperative opti-
misation of stroke volume guided by the oesophageal
Doppler technique with small colloid fluid challenges [16,
17].
Principles of perioperative fluid management represent a
major research topic for the coming years to optimise
recovery, also within the concept of fast-track surgery [17].
The challenges lie within procedure-specific approaches, goal-
directed therapy and the balance between the amount and
composition of colloid vs crystalloid. Furthermore, there is a
need to develop and document the optimal techniques to
monitor intra- and post-operative nomovolaemia.
Laparoscopic surgery
Minimal invasive surgery including laparoscopic surgery
has definite physiological advantages by decreasing pain
and the inflammatory response, thereby reducing demands
on the cardiopulmonary system, the gastrointestinal tract,
immuno-function, catabolism, etc. Several randomised
trials are available to show similar oncological outcome in
colorectal surgery and improved recovery with a slight
reduction in hospital stay, ileus, bleeding and wound
infection compared with open surgery [18]. However, in
all these randomised trials, conventional care principles
have been utilised and not adjusted to the principles of fast-
track surgery, thereby hindering the exact interpretation of
the potential benefits [18, 19]. Thus, from the many reports
on fast-track laparoscopic colonic surgery, significant
additional improvements in recovery and reduction of
hospital stay and morbidity have been demonstrated [18,
20] compared with those demonstrated in the randomised
trials. In the only patient- and observer-blinded trial
comparing open vs laparoscopic fast-track colonic resec-
tion, no differences were demonstrated in several physio-
logical recovery outcomes and hospital stay (2–3 days) in
elderly high-risk patients [21]. A more recent unblinded,
but randomised, trial using fast-track principles of care [22]
showed faster recovery with the laparoscopic technique in
colorectal surgery, but unfortunately, the epidural analgesia
was insufficient in most patients in the open group [22],
which otherwise has been demonstrated to be crucial to
optimise recovery [1, 2].
The future research initiatives within laparoscopic
surgery must therefore include a combination of the
497
advantages of minimal invasive surgery combined with
the principles of fast-track surgery. Further significant
improvements to reduce morbidity, especially in high-risk
patients, and hospital stay may be expected by such an
approach [18], and maybe even further when combined
with more effective pharmacological reduction of surgical
stress [23]. Future research should also focus on more
complex laparoscopic abdominal procedures, such as major
upper abdominal procedures, rectal amputation, total
colectomy with pouch, etc., combined with fast-track
principles of care.
Stress-reduction
The basic mechanism for the development of post-operative
organ dysfunction is the surgical stress response, consisting
of a combined endocrine metabolic component and an
inflammatory response component. Local anaesthetic
nerve-blocking techniques are the most efficient to block
the endocrine metabolic component (and pain) [2], while
several techniques are available to modify the inflammatory
responses. However, it remains as a key research topic to
evaluate which parts of the inflammatory response to
reduce, and by how much, to achieve the right balance
between the advantageous effects and the potential disad-
vantageous effects (decreased wound healing, risk of
infection, etc.). Minimal invasive surgery has been demon-
strated to be an important technique to reduce the
inflammatory response (due to reduced wound size), but,
more recently, several other interesting pharmacological
techniques have been studied, such as glucocorticoids,
statins, insulin (due to an anti-inflammatory effect),
systemic lidocaine, etc. [23]. Future research should
therefore focus on a combination of these pharmacological
stress-reducing techniques together with other care princi-
ples of fast-track surgery to achieve a more efficient “pain-
and stress-free” operation.
Organisational issues
Despite the fact that the principles of fast-track surgery
have been available and documented for several years,
changes of clinical practise have been very slow [24, 25],
which is quite surprising because fast-track surgery just
represents a combination of single-modality, evidence-
based care principles into a package using conventional
discharge criteria. There is therefore a major demand for
increased multi-disciplinary collaboration between anaes-
thesiologists, surgeons and surgical nurses to implement
evidence-based data in fast-track surgery. Such efforts may
include a more active collaboration within anaesthesia and
498
intensive care personnel in the wards to achieve earlier
identification of patients at risk for developing severe organ
dysfunction, thereby reducing admittance to intensive care
units and severe morbidity and mortality [26]. The
approach to establish an “intensive care outreach service”
in the surgical wards obviously may be controversial
among surgeons but requires detailed future study because
it seems logical to combine anaesthesiological and surgical
expertise and efforts in the overall care of the patients at
highest risk.
Conclusions
Progress within the concept of “fast-track surgery” has been
extensive during the last few years and has had more
widespread acceptance due to a better understanding of the
basic principles of perioperative pathophysiology and a
wish to improve the quality of perioperative care and
enhancing recovery, thereby subsequently reducing the need
for hospital stay and convalescence. However, the concept
is per definition multi-factorial, and therefore requires
intensive research and documentation in different surgical
procedures, each of which has its own pathophysiological
problems to improve recovery and decrease risk. Undoubt-
edly, further major improvements in outcome lie ahead
within the concept of fast-track surgery, and hopefully the
concept will be more widely implemented as an important
component of perioperative surgical research.
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