Development of the fast-track care protocol

4 Patients and Methods

7 FUTURE PROSPECTIVES 7.1 Robotic surgery

7.2 Development of the fast-track care protocol

Transversus abdominal plane (TAP) blocks is a potentially valuable pain management technique, and over the last 6 years, several clinical tials have demonstrated the efficacy of TAP blockade after laparoscopic colon surgery. Firstly, non-randomized trials indicated that TAP blockade with an enhanced recovery pathway contribute to a shorter length of stay after laparoscopic colectomy without increasing either complication or readmission rates (Zafar et al. 2010, Favuzza et al. 2012). Subsequently, randomized trials have shown that TAP blocks in patients undergoing laparoscopic colorectal resection reduced opioid use during the first postoperative day (Walter et al. 2012, Keller et al 2014). Later, a randomized trial investigating 226 patients demonstrated that TAP blockade appeared to be a safe intervention but conferred no specific advantage following laparoscopic colorectal surgery (Smith and al. 2015).

Perioperative intravenous lidocaine has also been shown to reduce postoperative pain, opioid requirements, and to shorten the length of the operative stay after laparoscopic colorectal surgery (McCarthy et al. 2010). Large randomized clinical trials are needed to reveal the utility of perioperative intravenous lidocaine in routine use (Joshi et al. 2012).

Minor new findings are that laparoscopic colonic resection without urinary drainage is safe and feasible (Alyami et al. 2016). Kiran et al. showed that combined preoperative mechanical bowel preparation with oral antibiotics reduces surgical site infections compared with systemic antibiotic alone in elective colorectal surgery and these findings were supported in a meta-analysis conducted by Chen et al. (Kiran et al. 2015, Chen et al.

2016,). Oral magnesium oxide has now been abandoned as Andersen et al. proved that magnesium oxide did not enhance recovery of gastrointestinal function (Andersen et al.

2012).

Early peroral nutrition and postoperative mobilization are still the cornerstones of enhanced recovery pathways.

Despite the benefits of the fast-track programme, the sustainability of the fast–track protocol after its intial implementation remains a challenge. The Dutch team reported their follow-up at 3-5 years in the 10 selected successful hospitals (Gillissen et al. 2014).

According to their study, fast-track protocol adherence had declined from 75% to 67%. In particular, adherence to postoperative care elements had decreased considerably. A systematic audit of quality of fast-track elements is essential if one wishes to maintain adherence of clinical pathway and continuous re-evaluation of evidence is mandatory (Martin et al 2016).

7 Conclusions

1. The effectiveness of fast-track colorectal surgery, as reflected by a relatively good adherence to predefined fast-track elements, low morbidity, reduced reoperation and readmission rates, short postoperative hospital stay, and good patient satisfaction, indicated that our fast-track protocol had been successfully implemented and should form the mainstay of elective colorectal surgery.

2. Compared with open surgery, laparoscopic colonic resection within fast-track perioperative care was found to be safe, improved postoperative recovery with lower surgical morbidity, without significantly increasing in-hospital costs.

3. Laparoscopic wide mesocolic excision and central vascular ligation for colon cancer was proved to be a feasible technique for colon cancer surgery and achieved a good long-term oncologic outcome.

4. Spinal anesthesia for laparoscopic ventral rectopexy within fast-track perioperative care was proven to be safe, speeding up postoperative recovery and resulting in shorter hospital stay thereby improving the efficiency of fast-track perioperative care.

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In document Laparoscopic colorectal surgery and fast-track care (sivua 53-67)