International Journal of Surgery 12 (2014) S20eS22

Contents lists available at ScienceDirect

International Journal of Surgery

journal homepage: www.journal-surgery.net

Original research

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

Rita Compagna, Giovanni Aprea, Davide De Rosa, Maurizio Gentile, Giovanni Cestaro,

D
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

TE
a r t i c l e i n f o a b s t r a c t

Article history: Background: Fast-track program has been applied in several surgical fields. However, currently many
Received 15 May 2014 surgical patients are elderly over 70 years of age, and discussion about the application of such protocols
Accepted 15 June 2014 for elderly patients is inadequate. Materials and methods: The present study was designed to consider
Available online 23 August 2014
the safety and feasibility of application of a fast-track program after colorectal surgery in elderly patients.
A total of 76 elderly patients with colorectal cancer who underwent laparoscopic colorectal resection
Keywords:
Fast-track rehabilitation
Laparoscopic colorectal surgery
Elderly patients
C
were randomly assigned to receive either the fast-track care program (n ¼ 40) or the conventional
perioperative care protocol (control group, n ¼ 36). The fast track protocol included no preoperative
mechanical bowel irrigation, immediate oral alimentation and earlier postoperative ambulation exercise.
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
A
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
R

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.
ET

© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

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

until the recovery of bowel movement and bed rest in the imme-
Traditionally, patients undergoing colorectal surgery were diate postoperative period followed by ward ambulation on post-
treated within a perioperative care protocol, which included the operative days 1 or 2. Restarting oral alimentation was based on
R

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-
List of abbreviations: ERAS, enhanced recovery after surgery; FT, fast-track; ASA, tegies, including extensive preoperative counseling, no bowel
American Society of Anesthesiologists; IV PCA, intravenous patient controlled
analgesia; NSAIDs, non-steroidal anti-inflammatory medications; UICC, Union for
preparation, no sedative premedication, carbohydrate-loaded liq-
International Cancer Control. uids until 2 h before surgery, effective multimodal pain manage-
* Corresponding author. ment, short-acting anesthetics, adequate perioperative fluid
E-mail addresses: ritacompagna@libero.it (R. Compagna), aprea@unina.it management, small incisions, and no routine use of drains and
(G. Aprea), david.derosa@unina.it (D. De Rosa), magentile@unina.it (M. Gentile),
nasogastric tubes. Postoperative care includes early oral feeding,
gcestaro@unina.it (G. Cestaro), federer2987@hotmail.it (G. Vigliotti),
tommasobianco85@gmail.com (T. Bianco), guido.massa@libero.it (G. Massa), enforced mobilization, early removal of bladder catheter and
maurizioamato@gmail.com (M. Amato), smassa@unina.it (S. Massa), bruno. standard laxative [2].
amato@unina.it (B. Amato).

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.
D
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
TE
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-
C was recorded in patients in the fast-track program compared with
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-
A
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
R
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
ET
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
R
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
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
S22 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
D
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
TE
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
C [3] M. Gatt, A.D. Anderson, B.S. Reddy, P. Hayward-Sampson, I.C. Tring, J. MacFie,
conventional protocol for perioperative care management of
elderly patients undergoing laparoscopic colorectal surgery.
Ethical approval
A
Local Board approved the study.
Funding
R
All Authors have no source of funding.
Author contribution
Rita Compagna: Participated substantially in conception,
ET
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-
R
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.
References
[1] H. Kehlet, Multimodal approach to control postoperative pathophysiology and
rehabilitation, Br. J. Anaesth. 78 (1997) 606e617.
[2] B. Amato, M. Donisi, C. Rispoli, M. Gentile, L. Sivero, Enhanced recovery after
surgery (ERAS) program in the elderly: is it feasible? Chirurgia Turin 26 (4)
(2013) 307e308.
Randomized clinical trial of multimodal optimization of surgical care in pa-
tients undergoing major colonic resection, Br. J. Surg. 92 (2005) 1354e1362.
[4] C.K. Khoo, C.J. Vickery, N. Forsyth, N.S. Vinall, I.A. Eyre-Brook, A prospective
randomized controlled trial of multimodal perioperative management pro-
tocol in patients undergoing elective colorectal resection for cancer, Ann. Surg.
245 (2007) 867e872.
[5] B. Kaltoft, I. Gogenur, J. Rosenberg, Reduced length of stay and convalescence
in laparoscopic vs open sigmoid resection with traditional care: a double
blinded randomized clinical trial, Colorectal Dis. 13 (2011) e123ee130.
[6] L. Basse, D.H. Jakobsen, P. Billesbølle, M. Werner, H. Kehlet, A clinical pathway
to accelerate recovery after colonic resection, Ann. Surg. 232 (2000) 51e57.
[7] K. Holte, H. Kehlet, Postoperative ileus: a preventable event, Br. J. Surg. 87
(2000) 1480e1493.
[8] P. Bucher, P. Gervaz, C. Soravia, et al., Randomized clinical trial of mechanical
bowel preparation versus no preparation before elective left-sided colorectal
surgery, Br. J. Surg. 92 (2005) 409e414.
[9] C.E. Pineda, A.A. Shelton, T. Hernandez-Boussard, et al., Mechanical bowel
preparation in intestinal surgery: a meta-analysis and review of the literature,
J. Gastrointest. Surg. 12 (2008) 2037e2044.
[10] M.S. Vlug, J. Wind, E. van der Zaag, et al., Systematic review of laparoscopic vs
open colonic surgery within an enhanced recovery programme, Colorectal
Dis. 11 (2009) 335e343.
[11] S.R. Steele, T.A. Brown, R.M. Rush, et al., Laparoscopic v/s open colectomy for
colon cancer: results from a large nationwide population-based analysis,
J. Gastrointest. Surg. 12 (2008) 583e591.
[12] J. Andersen, H. Christensen, J.H. Pachler, et al., Effect of the laxative magne-
sium oxide on gastrointestinal functional recovery in fast-track colonic
resection: a double-blind, placebo-controlled randomized study, Colorectal
Dis. 14 (2012) 776e782.
n, E. Wennberg, Fast-track concepts in major open upper abdominal
[13] M.F. Olse
and thoracoabdominal surgery: a review, World J. Surg. 35 (2011)
2586e2593.
[14] K. Azimuddin, L. Rosen, J.F. Reed III, J.J. Stasik, R.D. Riether, I.T. Khubchandani,
Readmissions after colorectal surgery cannot be predicted, Dis. Colon Rectum
44 (2001) 942e946.
[15] B. Amato, L. Sivero, G. Vigliotti, M. Gentile, M. Donisi, Surgery for cancer in the
elderly: state of the art, Chirurgia Turin 26 (4) (2013) 313e315.
[16] C. Rispoli, N. Rocco, L. Iannone, B. Amato, Developing guidelines in geriatric
surgery: role of the grade system, BMC Geriatr. 9 (Suppl. 1) (2009) A99.
[17] D. Loffredo, A. Marvaso, S. Ceraso, B. Amato, M. Cinelli, Minimal invasive
surgery in treatment of liver metastases from colorectal carcinomas: case
studies and survival rates, BMC Surg. 13 (Suppl. 2) (2013) S45, http://
dx.doi.org/10.1186/1471-2482-13-S2-S45.
[18] S. Perrotta, G. Quarto, V. Desiato, B. Amato, G. Benassai, TEM in the treatment
of recurrent rectal cancer in elderly, BMC Surg. 13 (Suppl. 2) (2013) S56,
http://dx.doi.org/10.1186/1471-2482-13-S2-S56.