Techniques in Coloproctology
https://doi.org/10.1007/s10151-018-1799-9
CORRESPONDENCE
What is fast track multimodal management of colorectal cancer
surgery in real life?
Bertrand Trilling1,2 · Pierre‑Yves Sage1 · Jean‑Luc Faucheron1,2
Received: 7 April 2018 / Accepted: 6 May 2018
© Springer International Publishing AG, part of Springer Nature 2018
Dear Sir,
We read recently an article comparing short-term outcome
of laparoscopic surgery for colorectal cancer with a multi-
modal full fast track (FFT) or limited fast track (LFT) care
program [1]. Based on a meta-analysis of the literature,
the authors hypothesized decreased postoperative morbid-
ity after the FFT program. According to the results of this
multicenter, single-blinded, randomized, superiority trial,
the authors delivered the message that a multimodal FFT
program might not have any benefit during laparoscopy for
colorectal cancer, as compared with a LFT program. Our
experience of FFT in colorectal surgery [2] leads us to make
some comments on this article.
First of all, the authors based their hypothesis around a
decreased postoperative morbidity rate reported in a meta-
analysis published in 2009. Four randomized clinical trials
that had been published since, and before the beginning of
Miggiori and colleagues’ study, should have been taken into
account as incorporation of their findings may have lead to
a different sample size for the study [3–6].
Second, we believe it is not possible to conducte this as
a single blind study, a comment already made by Dieter
Hahnloser at the end of the paper [1]. Surgeons, anesthe-
tists, nurses, dieticians, and physiotherapists are involved in
enhanced recovery programs and, therefore, the study could
not be blinded. As a simple example, if the patient is sitting
beside his bed and eating on the evening of the operation, we
are sure he has been randomized in the FFT group! Moreo-
ver, it is stated that the “operating surgeon was blinded to the
* Jean‑Luc Faucheron
JLFaucheron@chu‑grenoble.fr
1
Colorectal Unit, Department of Surgery, Michallon
University Hospital, CS 10217, 38043 Grenoble cedex,
France
2
Grenoble Alpes University, UMR 5525, CNRS,
TIMC-IMAG, Grenoble, France
randomization process”, but it is also mentioned further that
there was “infiltration of surgical wounds with Ropivacaine”
in the FFT group, which by definition is not blind.
Third, we do not understand why 10% of patients who had
a colectomy for cancer had a stoma, considering exclusion
criteria of emergency, obesity, denutrition, unfit patients,
and high-grade tumors. More than 55% of the patients in the
entire cohort had a stoma.
Fourth, mean operation time was significantly longer in
the FFT group. This means that the operations in this group
were more complex, or were performed in more complicated
cases, or by less expert surgeons or anesthetists, or that some
factors were not taken into account in the trial. The longer
the operation lasts, the less chance for ambulatory or fast
track management, and the more frequent complications are.
This factor in itself could explain why at the end there was
no difference between the two groups.
Fifth, FFT includes 20 items that were clearly described
by Kehlet in 1997 [7]. We can see that the most important
items in the FFT and LFT were applied in the study. Anti-
biotic prophylaxis and thromboprophylaxis were not cited,
but we presume that the authors followed these guidelines.
In the study the differences between FFT and LFT only con-
cern a few minor items. Compared to FFT, LFT comprised
absence of preoperative specific information, routine pre-
anesthetic medication, no preoperative carbohydrate loads,
free per-operative intravenous fluid infusion, standard per-
operative hemodynamic optimization, no intravenous infu-
sion of lidocaine, no ropivacaine infiltration, free opiate
analgesia, and progressive mobilization and oral intake
starting on postoperative day 1 instead of day 0. A major
criticism of this study is the absence of anesthesists as co-
authors. A fast track program is clearly a multidisciplinary
management of the patients. Hence, we cannot be sure that
anesthesists were not applying what is now considered as the
gold standard during colorectal surgery, for instance opti-
mal per-operative fluid infusion regime and hemodynamic
monitoring [3]. The authors do not mention whether or not
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patients received dexamethasone, gabapentin, or droperidol,
which also prevent postoperative nausea. In fact 14% of the
patients from the FFT group did not receive a preoperative
carbohydrate load, 32% did not have optimized hemody-
namic monitoring, and 77% did not receive odansetron,
as in the LFT group! We are surprised that patients in the
LFT group were not given specific information about the
pathology, the procedure and the global management. since
in France, this is mandatory. Moreover, before starting the
procedure, surgeons, anesthetists and nurses in the opera-
tive room must perform a surgical time out which includes
what is expected during and after the operation. Concern-
ing specific information, we cannot believe that surgeons
and anesthetists did not explain to the patient what is nowa-
days considered as evidence-based medicine. Therefore,
it is untrue that “no counseling” was applied in the LFT
group. Concerning the difference between the two groups,
we do not think that “last meal until midnight” and “last
meal 6 h before surgery” makes a big difference in real life.
Of course in the FFT group, some patients probably were
given hydroxyzine (we do not know how many), which is
what is systematically done in the LFT group. We imagine
that postoperatively patients in the LFT group also received
paracetamol and even nefopam, and not only opiates. We
wonder why patients in the FFT group received carbohy-
drate loads postoperatively, as it is not routine in enhanced
recovery after surgery programs because patients have a nor-
mal diet. If a patient was randomized to the FFT group and
developed nausea, he was probably prescribed some anti-
nausea drug and did not have “early” feeding. In some cases,
in our experience, patients are not always operated on early
in the morning; and, therefore, return to the ward late, so that
early feeding and mobilization are not possible. We cannot
imagine that in the FFT group, all 130 patients returned to
the ward early in the day.
In conclusion, we feel that there are significant methodo-
logical biases in the Maggiori study, contributing to a type
13
Techniques in Coloproctology
II error, and also because LFTmultimodal management of
colorectal cancer surgery is not so different from fFFT man-
agement in real life.
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent For this type of study, formal consent is not required.
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