Fast-Track Surgery – Conditions and Challenges in Postsurgical Treatment: A Review of Elements of Translational Research in Enhanced Recovery after Surgery

Abstract

Background: Enhanced recovery after surgery (ERAS) or fast-track surgery is a perioperative and postoperative care concept initiated in the early 1990s aiming to reduce the length of hospital stays following elective abdominal surgery. Twenty treatment items defined in the Consensus Guidelines established in 2009 were included in this concept. The success of ERAS depends highly on multidisciplinary teamwork and patient compliance. Several ERAS items and their impact on perioperative and postoperative care have recently been discussed. In this connection, translational research topics triggered increasing interest in ERAS and new impulses aimed at improving the ERAS concept. We thus reviewed the surgical literature to highlight the role of translational research items in ERAS. Methods: A literature search of Medline®, PubMed® and the Cochrane Database was performed. Two investigators independently reviewed the abstracts and appropriate articles were included in this review. Results: Articles have been selected. The advantages of the ERAS concept over conventional postoperative care were established by four meta-analyses and several reviews. But, due to the lack of standardization of the protocols, the level of evidence is still low. The implementation of ERAS into clinical practice is furthermore hampered by the poor compliance with ERAS protocols and remains a challenge for the future. Moreover, recent trials challenge the role of some ERAS items, e.g. epidural anesthesia. Translational research trials investigating stress, immune and inflammatory response after surgery, new analgesic concepts, goal-directed fluid therapy and new drugs and substances to improve the outcome of ERAS provide first promising data but still need to be integrated in the ERAS concept. Conclusion: The Consensus Guidelines for ERAS are subject to the constant evolution of treatment strategies and implementation of translational research findings. Improvement of the compliance with ERAS protocols in surgical clinics and updating of ERAS items taking into account recent findings in translational research may improve the outcomes of ERAS but remain a long-term challenge in surgery for the next years.

A meta-analysis of fast track surgery for patients with gastric cancer undergoing gastrectomy

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Is fast track rehabilitation already standard in gastrointestinal surgery?

“…In order to establish fast track recovery already as standard procedure, definition of essential elements to fulfill, exact definition of some of these elements, and adaptation to less invasive laparoscopic techniques require further investigation [27].…”

“…Forced discharge on day 2 as proposed by Kehlet in the first studies is influenced by economic considerations. In many European countries early discharge is not compensated financially [27]. Therefore, it does not make sense to force early discharge of patients as nursing capacities are historically calculated on a mix of early postoperative patients with intensive nurse care and patients recovering from surgery more than 5 days ago with less workload for the nursing staff.…”

Feasibility and safety of radical cystectomy under combined spinal and epidural anesthesia in octogenarian patients with ASA score ≥3: A case series

“…3 To evaluate the risk of surgery, the American Society of Anesthesiologists (ASA) has established the ASA score, depending on patients' comorbidity and physical status. 4 Today it is considered one of the most accepted instruments to classify surgical risk, including bladder cancer patients, candidates for RC. 5 An ASA class of 4 carries an odds risk ratio of 4.2 for perioperative complications, while an ASA class 3 an odds risk of 2.2, respectively.…”