PREOPERATIVE ASSESSMENT

Fast track surgery and

preoperative optimization

Components of fast track surgery

Enhanced recovery surgery is based upon four simple principles
(Box 1).4 Originally it was designed by a Danish surgeon, Henrik
Kehlet, with the main objective of providing a pain- and risk-free
procedure for patients.5 Since the initial application for colorectal
patients, these principles have been utilized in other surgical
subspecialties to achieve this outcome.

Alexander W Phillips
Alan F Horgan

Abstract

Preoperative components

Enhanced recovery pathways have been rapidly embraced by surgeons

as a mechanism for improving patient care and driving down complications and costs. They seek to employ a holistic approach, reviewing all
aspects of patient management, to improve care. Many components
are dissimilar to traditional surgical teaching, involving early mobilization and enteral nutrition, as well as a strong emphasis on fluid balance and pain management. By addressing all components of the
patient pathway from preoperative through to post-surgery, significant
improvement in outcomes can be achieved for a range of surgical
procedures.

Patient education
Fast track protocols place an emphasis on being patient centred
and empowering patients in making their decisions.4 To achieve
this, patients need to feel that they have an active part in deciding
that surgery is the right course of action, and this necessitates
excellent communication at all stages of their care. It is important
that patients fully understand what to expect at each stage of the
pathway and also the implications and alternatives to the treatment offered. Educating patients requires reiteration of information and a standardized pathway minimizes the chance of
misinterpretation and confusion. It may also be valuable for
patients to meet others that have gone through a similar experience and can answer questions in a more informal manner.
As well as providing a solid understanding to what is involved
in the patient pathway, education may also provide a valuable
opportunity to teach patients the skills they may require after
their surgery. This might involve meeting physiotherapists and
learning exercises that will aid rehabilitation and mobility, to
learning about how to manage stomas.6 It is also an ideal opportunity to involve those who might be involved in the patients
postoperative care once they are discharged e making them
aware of the problems that might be encountered, their limitations, and how best they will be able to help.

Keywords Enhanced recovery pathway; length of stay; optimization

support
groups
Introduction
Enhanced recovery pathways were originally conceived for the
management of colorectal patients and have become part of the
standard of care for these patients over the last 10 years1,2 with
the vast majority of NHS trusts having established these pathways. These involve a written multidisciplinary approach to
managing patients perioperatively. Enhanced recovery pathways
have been shown to improve clinical outcomes and consequently
drive down costs through shorter hospital stays and reduction in
morbidity. There has been an increasing trend for adopting these
principles in other general surgical specialties as well as orthopaedics, gynaecology and urology.3
Use of written, multidisciplinary, enhanced recovery pathways provides a number of advantages: they allow standardization of patient care, with good teamwork and reproducibility
of management with adaptability for individual patient needs.
This improves team function and confidence in managing
complicated patients postoperatively. They have also been
shown to reduce complications, length of stay and hence overall
costs.4
Most pathways comprise preoperative, intraoperative and
postoperative components which seek to streamline the patients
journey and optimize their care for major surgical procedures
(Figure 1). The overall aim is to minimize risk to the patient and
promote a speedier recovery.

Co-morbidity control
Identification of co-morbidities that might influence outcome has
become a standard practice in patient evaluation prior to surgery.
This allows both generic and procedure-specific problems to be
addressed prior to the patient undergoing surgery. The personnel
carrying out the pre-assessment may vary from trained nursing
staff who are able to carry out baseline investigations and refer
appropriately to an anaesthetist familiar with the procedure who
may want to request more advanced investigations such as cardiopulmonary exercise testing (see related article in this issue) in
those who are deemed higher risk, or in all patients undergoing
physiologically more demanding procedures. Many trusts will
have their own guidelines regarding pre-assessment processes,
which may range from a standardized nurse-led protocol, to
surgeons requesting anaesthetic reviews in those patients they
feel are higher risk, to a standard screening process and investigation matrix.
The impact of good preoperative preparation extends beyond
a reduction in mortality, to associated reductions in critical care
bed days and a reduction in frequency and severity of
complications.

Alexander W Phillips MA FRCSEd (Gen Surg) FHEA is a Consultant Surgeon at

the Freeman Hospital, Newcastle upon Tyne, UK. No conflicts of interest
declared.

Day of surgery admission

In general, most patients can be admitted on the day of their
surgery. This relies on other components of the enhanced

Alan F Horgan MD FRCS (Gen) is a Consultant Surgeon at the Freeman

Hospital, Newcastle upon Tyne, UK. No conflicts of interest declared.

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reduce risk of Sx

Common components of enhanced recovery pathway

REDOOC i.e.
"reduce"
Pre-admission

Optimization of co-morbidities
Optimization of haemoglobin
Consent/shared decision-making
Discharge planning
Education
Risk stratification

Day of surgery admission

Fluid optimization
Carbohydrate loading
No bowel preparation
(gastrointestinal surgery)

Minimally invasive approach

No nasogastric tube/drains
Individualized pain management
Goal-directed fluid management

Early mobilization
IV fluids as appropriate
Early enteral nutrition
Avoidance of opiate analgesics
Discharge planning

reduces ICU stay

reduces complications (frequency + severity

patient centred
clear communication
support groups
sensitize for post op
post op caretakers eg stoma nurse, physio
inform of limitations and stages of recovery

DO a Fancy job
C FAN
"sea fan"
Admission

MING

Intraoperative

FEEED
"Evade opioids"
Postoperative

Adapted from reference 4: Fulfilling the potential: A better journey for patients and a better deal for the NHS.

Figure 1

recovery pathway, with patients having been seen and managed

appropriately in a pre-assessment clinic, and having been
educated appropriately about what they can expect throughout
their stay.
It should be remembered that the consent process starts from
the time the patient has decided upon surgery as the appropriate
course of action, and involves education in outpatients and
ample opportunity for questions to be answered.
Day of surgery admission carries benefits for patients and
their families, as well as the admitting hospital minimizing the
number of days that a bed is required. Most patients prefer to be
in their own home on the day before surgery and this also
maximizes the time that can be spent with family.7

Principles of enhanced recovery surgery

C

All patients should be enrolled on a pathway allowing speedier

recovery and quicker discharge, minimizing physical and psychological stress
Patient preparation is required to optimize the patient for the
procedure, minimize risk and allow easy transition to a rehabilitation programme
Pro-active patient management components are inherent
throughout the pathway
Patients must be encouraged and empowered to take responsibility in their recovery

Carbohydrate loading
Preoperative nutritional state is an important consideration for
patients undergoing major elective procedures. In many cases the

Box 1

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operatively does little to affect these issues, and may in fact be

detrimental to patient recovery, causing discomfort, discouraging
oral intake and may be associated with a prolonged time to
passing flatus.5,14
The use of laparoscopic surgery e or minimally invasive
surgery e has perhaps had the biggest impact on patient recovery and consequently length of hospital stay. Laparoscopic surgery may not be an integral component of an enhanced recovery
pathway with open surgery being a valid method alongside all
the other pathway constituents. However, there has been a
gradual trend towards using minimally invasive techniques
because of the many advantages that it confers. Most of these
surround the fact that patients have less postoperative pain
which can mean more rapid mobilization, less need for medications that might prolong recovery, better oral intake and
improved respiratory effort reducing pulmonary complications.15
Further, smaller incisions are associated with lower infection
rates and are easier to manage. With respect to colorectal cancer
resections laparoscopic surgery has been accepted as allowing at
least as good oncological clearance as open surgery.16

nature of the underlying condition will have led to a period of

poor intake and make the patient nutritionally deficient. Further,
the insult of surgery will induce a catabolic state and insulin
resistance, increasing the risk of postoperative complications. In
some instances it might be necessary to admit patients for
nasogastric tube feeding but this is required infrequently. More
commonplace in enhanced recovery pathways is the use of carbohydrate loading with preoperative carbohydrate drinks being
used close to the time of surgery. This attenuates insulin resistance and reduces the need for aggressive postoperative insulin
management, leading to reduced morbidity and mortality and
shorter hospital stays.8
Avoidance of bowel preparation
Traditionally patients undergoing colonic resections would have
oral bowel preparation prior to surgery. Enhanced recovery
programmes advocate avoiding this due to the impact it can have
in disturbing electrolyte and fluid balance; this can be particularly marked in the elderly or those more frail. Studies have
shown that omission of bowel preparation has no detrimental
postoperative impact.9,10

Pain management
Historically, pain control has been very poorly achieved and
there is no doubt that this is detrimental to patient recovery and
associated with morbidity. Good pain control is a vital component of enhanced recovery programmes. The PROSPECT website
(procedure specific postoperative pain management) publishes
the work of the PROSPECT collaborative group chaired by
Henrik Kehlet which evaluates the evidence for postoperative
analgesia in different surgical specialties.17 Their suggestion is
that postoperative pain control can be optimized by examining
procedure specific protocols rather than pooling data from
different surgical procedures and specialties.
The type, dose and length of time different analgesics will
be required will vary from patient to patient and from procedure to procedure. This website allows an easy review of evidence to determine the optimal approach for particular
procedures. Explicit recommendations of what analgesics are
to be used within any pathway ensures familiarity and correct
prescribing of drugs which will have a powerful positive
impact on postoperative recovery. Patients are more likely to
progress through pre-determined goals, suffer fewer painassociated complications, and judicious use of opiates allows
rapid restoration of gut function.

Intraoperative components
Fluid management
Perioperative fluid management is a key component to enhanced
recovery programmes. Whilst this starts pre-operatively with the
use of carbohydrate drinks, avoidance of bowel preparation and
adequately hydrating the patient, it is imperative that this care is
followed through to the intraoperative and postoperative phases.
Intraoperative fluid therapy management is evolving, but still
includes basic cardiovascular parameters such as pulse and
blood pressure. More invasive techniques for monitoring fluid
balance such as central venous pressure is commonplace in some
surgical procedures, and enhanced recovery protocols have
embraced a goal-directed therapy (GDT) approach producing a
significant improvement in outcome.10 Many enhanced recovery
protocols specify the use of oesophageal Doppler monitoring as a
means of ensuring goal-directed targets are met.11 This ensures
the patient remains normovolaemic, reducing the risk of gut
hypoperfusion and its associated morbidity. Randomized
controlled trials have demonstrated that avoiding hypoperfusion
is associated with reduced length of hospital stay not only in
patients undergoing gastrointestinal surgery but also those having cardiac and orthopaedic surgery.12,13 In the UK, the National
Institute for Health and Care Excellence has recommended the
routine use of GDT.

Postoperative components
Some of the greatest changes that have been embraced by
enhanced recovery protocols are within the postoperative phase.
There has been move towards encouraging a swifter recovery by
ensuring early mobilization, and early intake of nutrition. Much
of this is dictated by a standardized set of goals that patients
should try and attain on each of their postoperative days and
promotes patient progress and consequently facilitates families in
helping the patient achieve daily goals.
Initiation of oral intake, within 24 hours of surgery, has now
become the mainstay, even in specialties such as colorectal surgery, where traditionally eating was left until the patient had passed
flatus, and was then tentatively commenced on a soup, jelly, ice-

Surgical decisions
Enhanced recovery protocols include a number of changes from
historic common practice. For example, use of abdominal drains
should not be routine, to encourage mobilization, and minimize
drain-associated complications.
Routine use of nasogastric tubes has also been discarded
within enhanced recovery protocols, having previously been
believed to alleviate postoperative vomiting and decompress the
gastrointestinal tract in case of ileus and reduce the risk of
anastomotic leaks as well as pulmonary infections. However,
studies have demonstrated that nasogastric drainage post-

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cream diet. Patients are encouraged to start a normal diet as they

feel able. After surgery, return of bowel function and motility
usually occurs within 6e12 hours in the small bowel, 12e24 hours
in the stomach, and 48e72 hours in the colon.18 Early eating has
been shown to reduce the incidence of postoperative ileus (and
consequently length of stay) as it is thought that feeding stimulates
gastrointestinal hormones, and leads to gut propulsion.19 There is
no evidence to suggest that early feeding increases the risk of
anastomotic leak.20,21 Use of chewing gum has also been advocated
as a method of stimulating early gut motility but there have been
mixed results from studies to date.

in an enhanced recovery pathway are less likely to encounter

more major complications.4
Patient satisfaction
The initial adoption of enhanced recovery protocols in the UK
was slow for a variety of reasons, including concerns about
outcomes, particularly for oncological surgery, and also concerns
that they might affect health related quality of life and patient
satisfaction. Some of these concerns arise from the proactive
nature of these pathways which encourage early mobilization
and early resumption of normal activities which may outwardly
appear as if care is being rushed.
Implementation of enhanced recovery pathways have, however, not been found to be associated with any deterioration in
patient care with regards to quality of life or patient satisfaction.
Indeed there is evidence that fatigue and pain may be reduced in
the early postoperative period in patients within an enhanced
recovery pathway.23 Results from laparoscopic surgery can be
further augmented when it is employed within an enhanced recovery pathway, although some studies have suggested that
there is no difference in quality of life between patients having an
open or laparoscopic procedure if enhanced recovery principles
are employed, suggesting the holistic nature of enhanced recovery pathways is the important factor.24

Proactive discharge planning

Ideally discharge planning should commence prior to admission
for the procedure usually within the preadmission clinic. This
helps guide what can be expected by the patient. According to
Fearon, patients are fit for discharge when they have met the
following four criteria:22
 have good pain control with oral analgesics
 are eating and drinking and not requiring IV fluids
 are independently mobile or have reached their preoperative level
 have met all of the above criteria and are willing to go
home.
Patients are often discharged home with literature informing
them about salient issues such as pain control, wound management and bowel and bladder control. Frequently they are supplied with a point of contact in case there should be any
problems in the immediate discharge period. Given that the
enhanced recovery programme promotes a swifter discharge
than patients previously experienced it is possible for some
complications to occur after they have gone home. Thus,
knowing who to contact in case of problems is an important
component of the discharge process and also impressing on patients that they should seek help at an early opportunity should
they become unwell or have concerns.

Cost implications
There have been few studies evaluating the cost-effectiveness of
enhanced recovery pathways. Roulin et al. recently reported their
findings with respect to cost-effectiveness of an enhanced recovery
pathway within colorectal surgery.25 As would be expected from
an enhanced recovery pathway patients had a significantly shorter
length of stay than with the previous standard care and suggested a
saving of over 1400 per patient. Other studies, again within
colorectal surgery, have suggested savings ranging from 200 to
4000. The impact of enhanced recovery pathways on length of
stay might account for the considerable saving that has been
suggested although previous studies have suggested that this
might have minimal impact on the overall cost. Instead, the impact
of the pathway on potentially minimizing complications and
optimizing patients with co-morbidities is likely to be a major
factor in the savings that are realized.

How fast track surgery affects outcomes

The introduction of enhanced recovery pathways has led to
benefits in length of hospital stay, complication rates, readmission rates and overall cost.
There has been a year-on-year increase in the UK of day of
surgery admissions (DOSA) within orthopaedics, gynaecology,
urology and colorectal procedures. Further, there has been fall
in the length of stay of patients undergoing major procedures
(primary joint replacements, hysterectomies, colonic resections and prostate and bladder resections) in all of these
specialties.
With respect to readmission rates, the data that have been
published have been variable. However, enhanced recovery
protocols have not been associated with an increased readmission rate, and indeed many have found a reduction in rates of
readmission.
Again there have been mixed reports regarding the outcomes
of enhanced recovery pathways compared to traditional routes
with respect to the incidence and severity of complications.
Enhanced recovery pathways are not associated with increased
complication rates and there has been some suggestion that those

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Conclusions
Enhanced recovery pathways, or fast track pathways have
gradually been adopted by a number of surgical specialties since
their initial inception in colorectal surgery by Kehlet. The underlying principles lie in the multimodal treatment of patients
with emphasis on optimizing their management at each stage of
their treatment and empowering the patient to take responsibility
for their own care.
The impact of these pathways has been multifactorial, promoting a more rapid recovery and consequently reducing patient
length of stay, with lower overall costs and a reduction in the rate
of complications. Further, they have been associated greater
patient satisfaction.
Many of the key themes used within enhanced recovery
pathways are transferable to most specialties and there have
already been attempts to use these ideas to improve patient care

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12 Sinclair S, James S, Singer M. Intraoperative intravascular volume

optimization and length of hospital stay after repair of proximal
femoral fracture: randomized controlled trial. Br Med J 1999; 315:
909e12.
13 Gan TJ, Soppitt AB, Maroof M, et al. Goal-directed intraoperative fluid
administration reduces length of stay after major surgery. Anesthesiol 2002; 97: 820e6.
14 Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of
selective versus routine nasogastric decompression after elective
laparotomy. Ann Surg 1995; 221: 469e78.
15 Nygren J, Soop M, Thorell A, Hausel J, Ljungqvist O. An enhancedrecovery protocol improves outcome after colorectal resection
already during the first year: a single-center experience in 168
consecutive patients. Dis Colon Rectum 2009; 52: 978e85.
16 Jayne DG, Thorpe HC, Copeland J, Quirke P, Brown JM, Guillou PJ. Fiveyear follow-up of the Medical Research Council CLASICC trial of laparoscopically assisted versus open surgery for colorectal cancer. Br J
Surg 2010; 97: 1638e45.
17 Procedure Specific Postoperative pain management. http://www.
postoppain.org (accessed 10 July 2013).
18 Finan MA, Barton DP, Fiorica JV, et al. Ileus following gynaecology
surgery. South Med J 1995; 88: 539e42.
19 Lubawski J, Saclarides T. Postoperative ileus: strategies for reduction.
Ther Clin Risk Manag 2008; 4: 913e7.
20 Bohm B, Haase O, Hofmann H, Heine G, Junghans T, Muller JM.
Tolerance of early oral feeding after operation of the lower gastrointestinal tract. Chirug 2000; 71: 955e62.
21 De Aguilar-Nascimento JE, Goelzer J. Early feeding after intestinal
anastomosis: risk of benefits? Rev Assoc Med Bras 2002; 48: 348e52.
22 Fearon KCH, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients
undergoing colonic resection. Clin Nutr 2005; 24: 466e77.
23 Khan S, Wilson T, Ahmed J, Owais A, MacFie J. Quality of life and
patient satisfaction with enhanced recovery protocols. Colorectal Dis
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24 Raue W, Haase O, Junghans T, Scharfenberg M, Mu
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surgery. Br J Surg 2013; 100: 1108e14.

in medical specialities and in acute surgical patients with an

eventual aim that enhanced recovery pathways will be the norm
for all hospital inpatients.
A

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