International Journal of Surgery 12 (2014) S20eS22

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International Journal of Surgery

j o u r n a l ho m e p a g e : w w w . j o u r n a l - s u r g
er y . n e t

Original research

Fast track for elderly patients: Is it feasible for colorectal surgery?

Rita Compagna, Giovanni Aprea, Davide De Rosa, Maurizio Gentile, Giovanni Cestaro,
Gabriele Vigliotti, Tommaso Bianco, Guido Massa, Maurizio Amato, Salvatore Massa,
Bruno Amato*
Department of Clinical Medicine and Surgery, University of Naples Federico II, Via S. Pansini, 5, 80131 Napoli, Italy

a r t i c l e i n f a b s t r a c t
o
Background: Fast-track program has been applied in several surgical fields. However, currently many
Article history: surgical patients are elderly over 70 years of age, and discussion about the application of such protocols
Received 15 May 2014 for elderly patients is inadequate. Materials and methods: The present study was designed to consider
Accepted 15 June 2014
the safety and feasibility of application of a fast-track program after colorectal surgery in elderly patients.
Available online 23 August 2014
A total of 76 elderly patients with colorectal cancer who underwent laparoscopic colorectal resection
were randomly assigned to receive either the fast-track care program (n ¼ 40) or the conventional
Keywords:
perioperative care protocol (control group, n ¼ 36). The fast track protocol included no preoperative
Fast-track rehabilitation
mechanical bowel irrigation, immediate oral alimentation and earlier postoperative ambulation exercise.
Laparoscopic colorectal surgery
Elderly patients
The length of postoperative hospital stay, the length of time to regain bowel function and the rate of
postoperative complications were compared between the two groups. Results: The length of time to
regain bowel function, including the passage of flatus [32 (24e40) h vs 42 (32e52) h], and to start a
liquid diet (13 [10e16] h v/s 43 [36e50] h) were significantly shorter in patients receiving the fast track
care protocol compared with those receiving the conventional care protocol. A shorter duration of
postoperative hospital stay was recorded in patients receiving the fast-track program than in those
receiving conventional care [6 (5e7) days v/s 9.5 (7e12) days]. A reduced percentage of patients who
developed general complications was also observed in the fast-track group (5.0% v/s 18%). Conclusion:
Fast-track after laparoscopic colorectal surgery can be safely applied in carefully selected elderly patients
older than age 70 years. The fast-track recovery program resulted in a more rapid postoperative recovery,
earlier discharge from hospital and fewer general complications compared with a conventional post-
operative protocol.
© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction use of a nasogastric tube, starvation for several postoperative days

Traditionally, patients undergoing colorectal surgery were
treated within a perioperative care protocol, which included the
List of abbreviations: ERAS, enhanced recovery after surgery; FT, fast-track; ASA,
American Society of Anesthesiologists; IV PCA, intravenous patient controlled
analgesia; NSAIDs, non-steroidal anti-inflammatory medications; UICC, Union for
International Cancer Control.
* Corresponding author.
E-mail addresses: ritacompagna@libero.it (R. Compagna), aprea@unina.it
(G. Aprea), david.derosa@unina.it (D. De Rosa), magentile@unina.it (M. Gentile),
gcestaro@unina.it (G. Cestaro), federer2987@hotmail.it (G. Vigliotti),
tommasobianco85@gmail.com (T. Bianco), guido.massa@libero.it (G. Massa),
maurizioamato@gmail.com (M. Amato), smassa@unina.it (S. Massa), bruno.
amato@unina.it (B. Amato).
until the recovery of bowel movement and bed rest in the imme-
diate postoperative period followed by ward ambulation on post-
operative days 1 or 2. Restarting oral alimentation was based on
the passage of gas or faeces, usually several days following
surgery. The concept of fast-track (enhanced recovery after
surgery, ERAS) was introduced to colorectal surgical practice by
Kehlet [1]. Fast- track protocols combine multidisciplinary
perioperative care stra- tegies, including extensive preoperative
counseling, no bowel preparation, no sedative premedication,
carbohydrate-loaded liq- uids until 2 h before surgery, effective
multimodal pain manage- ment, short-acting anesthetics,
adequate perioperative fluid management, small incisions, and
no routine use of drains and nasogastric tubes. Postoperative care
includes early oral feeding, enforced mobilization, early removal
of bladder catheter and standard laxative [2].

http://dx.doi.org/10.1016/j.ijsu.2014.08.389
1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
 R. Compagna et al. / International Journal of Surgery 12 (2014) S20eS22
The concept of fast-track (FT) rehabilitation has been recently
introduced with the intent to improve perioperative management
by reducing stress and complications suffered by patients, short-
ening the length of hospital stay, and reducing costs of resection
of colorectal cancer. A systematic review that included several
ran- domized, controlled trials examined the evidence for fast
track protocols compared with traditional care [3e4]. Currently,
laparo- scopic surgery has been accepted as the surgery of
choice for colorectal cancer because it minimizes invasive injury
and has a comparatively safe profile. We set up a randomized
controlled clinical trial designed to evaluate the safety and
efficacy of a fast- track recovery program for elderly patients
undergoing laparo- scopic colorectal surgery comparing with
traditional care.
2. Material and methods
Participants were recruited from the Department of Gastroen-
terology, Endocrinology and Surgery, University Federico II of
Naples, from April 2010 to October 2013. Criteria for patients
selected for the study were as follows: age over 70 years; a diag-
nosis of colorectal cancer and undergoing laparoscopic colorectal
resection. Patients were excluded from the study if they were
younger than 70 years of age, they underwent an emergency sur-
gery, an American Society of Anesthesiologists (ASA) class IV, or
required postoperative intensive care or conversion to an open
procedure. A total of 76 patients were enrolled. After obtaining
informed consent, a randomization process was carried out. Over-
all, 40 patients were assigned to the fast-track rehabilitation pro-
tocol and 36 patients were assigned to the conventional care
group. Of the 76 patients in the study, 42 were men and 34 were
women. The median age for all patients was 72 years. Patients
underwent the following procedures: right hemicolectomy (n ¼
8), left hemi- colectomy (n ¼ 12), transverse colectomy (n ¼ 2),
sigmoid colec- tomy (n ¼ 40) and anterior resection (n ¼ 14).
The study was approved by the local Ethical Committee and
written informed consent was obtained from all patients before
participation in the study.
The protocols of fast-track rehabilitation programs typically
include no bowel preparation except one or two enemas in cases
of rectal surgery, continuation of a normal diet until 8 h before
sur- gery, no routine use of nasogastric tubes, postoperative pain
control with intravenous patient controlled analgesia (IV PCA),
and mini- mization of opioid use except for in patients with a
contraindication to non-steroidal anti-inflammatory medications
(NSAIDs). One or two doses of prophylactic antibiotics consisting
of a second- generation cephalosporin were used on the day of
surgery. On postoperative day (POD) 1, patients were permitted
water intake and urinary catheters were removed. Ambulation
was encouraged. For rectal cancer patients, the urinary catheter
was removed on the second or third postoperative day. Patients
were given a soft diet on POD 2.
On POD 3, a normal diet was permitted, IV fluid administration
was discontinued, and analgesia was changed to oral medicine if
appropriate. On the next day, any abdominal drains placed during
surgery were removed. Patients without problems were
discharged on POD 5.
Duration of anesthesia, duration of surgery, intraoperative
blood loss and complications, including wound infection,
anastomotic leakage, pulmonary infection, intestinal obstruction
and the length of hospital stay were recorded by the surgeon. The
time to passage of the first flatus, to ambulation and to diet were
self-reported by the patient and recorded by the nurse. Follow up
started immedi- ately after discharge from hospital through
telephone queries and was continued every 3 months thereafter at
hospital appointments. Discharge criteria were as follows:
tolerance of a normal diet
S21
without nausea or vomiting, adequately controlled pain, free
ambulation and defecation, no surgical complications,
normothermia.
3. Results
Of the 76 enrolled patients, 40 in the fast-track rehabilitation
group (FT group) and 36 in the conventional care group (control
group) were analyzed. No statistically significant differences in
baseline characteristics, age (71 v/s 72) and gender ratio (M22/F18
v/s M20/F16), were noted between the two groups. Duration of
surgery (130 min v/s 110 min), intra-operative blood loss (50 ml
v/s
55 ml) and numbers of lymph nodes resected (15 v/s 15) were not
significantly different between the fast-track group and the control
group.
Of the 76 enrolled patients, 15 were classified as stage I, 21 as
stage II and 40 as stage III based on the TNM classification system
of the Union for International Cancer Control (UICC). The length
of follow up ranged from 3 to 40 months. One patient had
local recurrence after rectal carcinoma surgery, one had hepatic
metas- tasis after right hemicolectomy, two patients died from
myocardial infarction and one patient died from hepatic
metastasis. No sig- nificant differences were observed in
mortality between the two groups. Significantly accelerated
recovery was found in patients receiving fast-track care
compared with patients receiving con- ventional care. A shorter
duration of postoperative hospital stay was recorded in patients
in the fast-track program compared with those in the control
group. A reduced number of patients devel- oping complications
was also observed in the fast-track group (5.0% v/s 18%).
4. Discussions
Laparoscopic colorectal resection is now a definite treatment for
colorectal cancer. Fast-track rehabilitation offers a multimodal
perioperative care plan for patients undergoing elective surgery
that reduces complications and speeds recovery also in elderly
patients. In contrast to protocols of classic perioperative care, the
fast-track rehabilitation protocol does not require fast infusion of
fluid, intestinal antibiotics and mechanical bowel preparation in
the perioperative period [5]. According to the fast-track protocol
regarding the limitation of fluid administration intra- and post-
operatively, elderly patients can avoid the fluideelectrolyte
imbalance that can be induced by preoperative prolonged fasting,
massive bowel preparation, and overloading of the cardiopulmo-
nary system. Using pneumatic compression stockings intra-
operatively and encouraging early ambulation can prevent throm-
boembolic complications. The restriction of opioids can reduce the
incidence of ileus and gastrointestinal symptoms, such as nausea or
vomiting, and related complications, such as aspiration [6]. Recent
studies have shown, however, that ileus can be significantly
reduced by the use of epidural analgesia with local anesthetics [7].
Preoperative bowel preparation in traditional colorectal surgery
involves oral administration of intestinal antibiotics for 3 days and
administration of a preoperative mechanical enema to clean the
faecal contents from the colon, aiming to reduce the numbers of
intestinal bacteria, thereby ensuring safe surgery. The practice is
widely adopted in clinics, but there is no clear evidence of benefit
for patients [8]. Instead, one study even showed that preoperative
bowel preparation was associated with higher risks of anastomotic
leakage and postoperative infectious complications [9]. Bacterial
translocation is possibly a detrimental effect of preoperative me-
chanical bowel preparation, caused by a reduction in the levels of
intestinal flora and reduced efficacy of the mucosal mechanical
barrier. Postoperative infection results in more treatment failures
in
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R. Compagna et al. / International Journal of Surgery 12 (2014) S20eS22
elderly patients as a result of weak immunity. Therefore, we did
not perform preoperative mechanical bowel preparation in
patients of the fast-track group [10]. Nowadays, more and more
laparoscopic surgery has been applied in the treatment of
colorectal cancer. This procedure significantly reduces trauma
and speeds up the reha- bilitation of patients following surgery.
Shorter hospital stay and lower rates of hospital readmission
have been reported [11].
5. Conclusion
In studies involving younger patients, similar effects, such as
shortening the length of time to the passage of flatus, to food
intake and to hospital discharge, and reduced rates of hospital
read- mission, were observed [12,13]. It may be argued that
fast-track colonic surgery could lead to a higher readmission rate,
but more than 65 percent of these readmissions occurred after
postoperative day five and therefore might not have been
prevented by a longer hospital stay. Also, other studies have
indicated that readmissions after colorectal surgery cannot be
predicted [14e18]. In the present study there were not
readmissions connected with acute life- threatening conditions,
even in the cases with anastomotic dehis- cence. Our
perioperative fast-track care program provided safe and effective
care management for elderly patients undergoing lapa- roscopic
colorectal surgery and also improved clinical outcomes in the
short term. The study has been continued for a further
assessment of its long-term effects in the elderly population. In
conclusion, a fast-track surgery recovery protocol is superior to a
conventional protocol for perioperative care management of
elderly patients undergoing laparoscopic colorectal surgery.
Ethical approval
Local Board approved the study.
Funding
All Authors have no source of funding.
Author contribution
Rita Compagna: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data.
Giovanni Aprea: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data; also participated substantially in the drafting
and editing of the manuscript.
Davide De Rosa: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data.
Maurizio Gentile: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data.
Giovanni Cestaro: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data.
Gabriele Vigliotti: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data.
Tommaso Bianco: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data.
Guido Massa: Participated substantially in conception, design,
and execution of the study and in the analysis and interpretation
of data.
Maurizio Amato: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data; also participated substantially in the drafting and
editing of the manuscript.
Salvatore Massa: Participated substantially in conception,
design, and execution of the study and in the analysis and inter-
pretation of data; also participated substantially in the drafting and
editing of the manuscript.
Bruno Amato: Participated substantially in conception, design,
and execution of the study and in the analysis and interpretation
of data.
Conflicts of interest
All Authors have no conflict of interests.
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