Fast Track Surgery Principles Research Articles

Enhanced recovery program in surgical treatment of patients with germ cell tumors of the testicle: experience of a specialized hospital

Background. Surgical treatment after chemotherapy is extremely difficult technically and should only be performed in a specialized medical center. The postoperative period after these surgical interventions is aimed not only at minimizing complications, but also at early mobilization and rehabilitation of patients. The principles of fast-track surgery, or ERAS (Enhanсed Recovery After Surgery) significantly reduce the incidence and degree of complications after various surgical interventions. However, the results of studies on the use of fast track in retroperitoneal lymphadenectomies have not yet been presented.Aim. To determine the effect of enhanced recovery program on treatment outcomes in patients with germ cell tumors of the testicle after retroperitoneal lymphadenectomy.Materials and methods. Retrospective analysis of 2 groups of patients (n = 93) treated at the N.N. Petrov National Medical Research Center of Oncology (Saint Petersburg) was performed. In the 1st group of patients, standard postoperative care after retroperitoneal lymphadenectomy was performed; in the 2nd group, fast track elements were used. Since the introduction of the ERAS protocol into clinical practice (September 2017), all patients have been included in the 2nd group.Results. The presence or absence of preoperative preparation did not affect the incidence of intraoperative complications (p = 0.031). There were significant differences in the duration of hospitalization between the 1st and 2nd groups –15.3 and 11.9 days (p = 0.03), respectively. Assessment of the pain syndrome using the Numeric Rating Scale for Pain (NRS) showed that median pain level in the 1st group was significantly higher than in the 2nd group: 5 ± 1.5 and 3 ± 1.7, respectively (p = 0.04), which indicates a more severe and less controlled pain syndrome in the 1st group of patients. The rate of infectious complications in the postoperative wound in the 2nd group was 3 cases versus 13 in the 1st group (p = 0.009). The rate of lymphorrhea in 2nd group was significantly lower (p = 0.003), median drainage duration was higher in 1st group (p <0.05). In the 2nd group, 70.6 % of patients did not require drainage, which was an important factor in rapid rehabilitation.Conclusion. The use of fast-track principles in patients after retroperitoneal lymphadenectomy significantly reduces the incidence of postoperative complications and rehabilitation time.

Principles of fast-track surgery in the treatment of giant uterine fibroids: а clinical case

The article addresses the treatment of uterine fibroids, which is still relevant. According to numerous studies, about 70% of females under 50 have uterine fibroids, the most common condition among perimenopausal women. The prevalence of giant forms is not high and accounts for less than 5% of all cases, especially at early diagnosis. The surgical strategy in such cases is individual and depends on many factors: size, location of nodes, and women's reproduction plans. In these clinical cases, the management of patients with giant uterine fibroids is presented according to the multimodal principles of fast-track surgery in a modern gynecological hospital. We described the main approaches in diagnosis, preoperative preparation, surgery features, and subsequent recovery to reduce the complication rate, the duration of inpatient treatment, and postoperative rehabilitation in the treatment of giant uterine fibroids.

Лечение внутриматочной патологии с использованием технологий fast track хирургии

Study Objective: Evaluation of the clinical effectiveness of the use of fast track surgery technologies in the treatment of submucosal uterine fibroids and endometrial polyps Study Design: Retrospective comparative study. Materials and methods. A retrospective comparative analysis of the data of 46 women was performed to assess the clinical effectiveness of the use of fast track surgery approach to treat intrauterine pathology. The 1st group included 23 women treated with the use of fast track surgery method. The 2nd group consisted of 23 women who underwent surgery with bipolar resectoscope in the gynecological hospital setting without the use of fast track surgery approach. Study Results. The complex application of fast track surgery technology components made it possible to achieve 100% efficiency in the treatment of intrauterine pathology, decrease pain-syndrome intensity in the postoperative period in 69.57% of women, ensure early mobilization of the patients and reduce hospital stay from 2–8 inpatient days to 2–2.5 hours. Conclusion. Implementing the fast track surgery principles into the treatment of patients with intrauterine pathology makes it possible to reduce a patient’s hospital stay, allows minimizing the consequences of the surgical injury and facilitates fast recovery of a woman. Keywords: intrauterine pathology, fast track surgery, diode laser, resectoscopy.

Effectiveness of the concept of fast-trak surgery for simultaneous laparoscopic hernioplastics and cholecistectomy

The aim of the research was to study the feasibility and effectiveness of simultaneous laparoscopic hernioplasty and cholecystectomy in patients with combined abdominal pathology. Material and methods. Simultaneous laparoscopic hernioplasty and cholecystectomy during 2015–2019 performed on 70 patients, including 49 (70 %) women, mean age 57.3 ± 6.5 g. In 37 patients the principles of Fast-track surgery were applied (group I), including thorough examination for diagnostics of combined abdominal pathology and clinically significant general somatic pathology; if necessary a course of therapy for full compensation of general somatic pathology was prescribed; during the operation of epidural prolonged anesthesia; choice in favor of laparoscopic technology; at the end of the operation – irrigation of the subdiaphragmatic space with local anesthetic; postoperatively: early drainage removal; withdrawal from opioids by prescribing parenteral paracetomol; activation of the patient 6-8 hours after surgery; on the day of surgery – use of chewing gum and fluid intake. In 33 patients the standard complex of perioperative management (group II) is applied. The immediate results of surgical interventions have been studied. Results. There were no significant complications during the operation and in the early postoperative period. In the first group, seroma (after open alloplasty) was detected in 2 (5 %) cases, and in the second group, small wound complications were detected in 4 (12 %) cases (p > 0.05 according to the χ2 criterion). The duration of inpatient treatment in patients of group I is 4.4 ± 1.2 months, in group II – 7.0 ± 1.3 days (р < 0.001 by Student’s test). Conclusion. Application of the principles of Fast-track surgery and accelerated recovery at all stages of simultaneous laparoscopic hernioplasty and cholecystectomy (preparation for surgery, during the operation and in the postoperative period) does not increase the number of postoperative complications and decreased duration of inpatient treatment from 7,0 ± 1,3 in patients with traditional postoperative management to 4,4 ± 1,2 days.

«NONSURGICAL» ASPECTS OF SUCCESSFUL IMPLEMENTATION OF FAST TRACK PRINCIPLES INTO A SURGICAL CLINIC: OUR EXPERIENCE

Introduction. The main postulate of Fast track surgery according to H. Kehlet is the reduction of negative moments in the postoperative period by reducing the intensity of the body’s stress response to surgery.The purpose of the work. Evaluate the effectiveness of the implementation of Fast track principles in the work of the surgical clinic.Materials and methods. In the period from September 2011 to January 2019, we performed 623 planned surgeries using the principles of Fast track surgery, including the use of multimodal analgesia (MMA) and nutritional support for patients.Results. In the control group on the subjective scale of VAS, patients rated the pain level at 6.26 ± 1.52 points, in the experimental group – at 2.74 ± 1.05 (P <0.001). The average length of stay in the hospital was 4.99 ± 0.45 and 4.10 ± 0.60 days, respectively. The indicator of general weakness in the control group was 6.47 ± 1.26 points, in the experimental group – 2.26 ± 0.86 (P <0.001). Depressive states in the first days after surgery are the result of the above complaints and feelings, in the control group, this figure averaged 4.79 ± 1.07 points, at the same time, in the experimental – 1.50 ± 0.86 (P <0.001).Conclusions. The use of the principles of Fast track surgery, namely multimodal analgesia in the perioperative period in combination with preoperative oral carbohydrate loading and early recovery of oral nutrition with adapted mixtures significantly affects the level of pain impulses in the first postoperative day.

WAYS OF PREVENTION SYNDROME OF INTRA-ABDOMINAL HYPERTENSION IN BARIATRIC SURGERY

Patients with obesity who have undergone intra-abdominal endoscopic intervention belong to the category of patients with an increased risk of developing the syndrome of intra-abdominal hypertension (SIAH), which dictates the need to develop interventions aimed at its prevention.The OBJECTIVE was to evaluate the effectiveness of complex integrated methods of SIAH prevention in patients with morbid obesity with endoscopic bariatric surgery.MATERIAL AND METHODS. A randomized trial of 69 patients with a body mass index >35 kg/m INTENSIVE 2 was conducted; patients were divided into two groups depending on the type of anesthesia. In the 1st group (n=34), the operation was performed under combined anesthesia based on low-flow inhalation with desflurane in combination with prolonged epidural analgesia (PEA) with ropivacaine. Maintaining a deep level of myorelaxation under the control of acceleromyography in the post-tetanic counts (PTC) mode was achieved by continuous infusion of rocuronium. In the perioperative period, the infusion patients were in the «beach chair» position, and their research was carried out according to the principles of fast track surgery. In the 2nd group (n=35), the operation was performed under combined anesthesia based on lowflow inhalation with desflurane, neuromuscular blockade was performed by bolus injection of rocuronium under the control of acceleromyography in train of four (TOF) mode. Analgesia was provided by systemic administration of opioids. In both groups, markers of kidney injury were investigated, intra-abdominal pressure was monitored, the effectiveness of recovery after surgery and the quality of postoperative analgesia were assessed.RESULTS. A significantly lower level диурез of intra-abdominal pressure (IAP), связь higher compliance evaluation of the anterior crit abdominal внутрибрюшной wall, and a significantly стаканов lower level управляемой of markers of renal study injury in the отмечено postoperative period bariatric were revealed raga in the first дозе group compared to the second group during темпу the perioperative study period. keulenaerСONCLUSION. The effectiveness of using the position of deep muscle relaxation in the continuous infusion mode, adequate analgesia in the perioperative period using neuraxial techniques, using the «beach chair» position on the operating table and in the postoperative period, managing patients using fast track surgery for preventing the development of SIAG was identified.The authors declare no conflict of interest.The authors confirm that they respect the rights of the people participated in the study, including obtaining informed consent when it is necessary, and the rules of treatment of animals when they are used in the study. Author Guidelines contains the detailed information.

APPLICATION OF THE FAST TRACK PRINCIPLES OF SURGERY IN THE TREATMENT OF A PAZ PROLAPSE

The article describes the experience of applying the principles of fast track surgery in 46 patients with pelvic prolapse. 1 group - 20 women who underwent perioperative management using the principles of accelerated rehabilitation, 2 group (26 women) - perioperative management according to the traditional method. The duration of hospitalization in 1 group was about 1.5 times less compared to the second, without reducing the effectiveness of treatment.

Teaching the Principles of FAST TRACK Surgery in the System of Additional Professional Education

Teaching the Principles of FAST TRACK Surgery in the System of Additional Professional Education

Early enteral nutrition in surgical treatment of an acute complicated pancreatitis

Objective. To estimate the efficacy of early enteral nutrition (EEN) in patients with an acute complicated pancreatitis, after determining of its content and improving the realization methods.
 Маterials and methods. There were studied the results of EEN in 82 patients, suffering an acute complicated pancreatitis. Two groups of patients were delineated - the main (n=58), in which EEN was included into the complex of treatment in preoperative and postoperative periods, and a comparative one (n=24). For conduction of EEN the probe was put during fibrogastroscopy into jejunum (in 25 patients), while suboperative nasogastrointestinal intubation was performed (in 12), and a jejunostomy in accordance to Witzel procedure was formatted (in 21), what have appeared the most effective procedure and served for realization of the Fast track surgery principles.
 Results. Nutritious food blends were applied in combination with probiotics and the metabolism correctors. Application of EEN in the patients іn an acute complicated pancreatitis have promoted more rapid restoration of a motor-evacuation function of a small bowel, normalization of levels of the blood leukocytes and proteins, weakening of microstructural changes in mucosa and «clearance» of purulent-necrotic focus.
 Conclusion. EEN in the patients, suffering an acute complicated pancreatitis constitutes an effective component of surgical treatment in preoperative and postoperative periods.

Acute Appendicitis: Approaches to Complex Surgical Treatment in Accordance with the Principles of Multimodal Surgical Strategy (Fast-Track Surgery)

The objective of the research was to develop approaches to complex surgical treatment of patients with acute appendicitis taking into consideration the type of surgical approach, perioperative antibiotic therapy, adequate pain relief, duration of inpatient treatment. Materials and methods. The analysis of complex surgical treatment of the group of patients (31) with acute appendicitis, treated in the surgical departments of Lviv Emergency Hospital during 2017 was performed. The age of patients ranged from 18 to 77 years. There were 13 (41.9%) males and 18 (58.1%) females. Duration of hospital stay from the moment of hospitalization varied from 2 to 13 days. The level of pain sensation in patients was assessed on a 10-point visual analog scale of pain 6, 12 and 24 hours after surgery (with four-step stratification of the received data - absent (0-2), weak (3-4), moderate (5-8), strong (9-10 points). All the patients were divided into two groups using blind envelope technique: Group A included 18 patients, who underwent conventional appendectomy, and Group B comprised 13 patients who underwent diagnostic laparoscopy with the transition to laparoscopic appendectomy if the diagnosis of acute appendicitis was confirmed, or laparoscopic appendectomy was initially performed. The analysis of treatment efficacy was performed taking into account the dynamics of pain relief and the duration of inpatient treatment. Results and discussion. As a result of the conducted research it was stated that among all the patients examined, catarrhal acute appendicitis was found in 1 (3.2%) case, acute phlegmonous appendicitis was detected in 20 (64.5%) cases, acute gangrenous appendicitis was seen in 7 (22.6%) cases, acute gangrenous appendicitis with perforation and local peritonitis was diagnosed in 3 (9.7%) cases. Conventional appendectomy was performed in 18 cases; laparoscopic appendectomy was used in 13 cases. All the patients received anti-bacterial treatment in the early perioperative period. According to the prospective analysis, pain syndrome at the site of postoperative wounds was found to be present in patients of both groups. The intensity of pain syndrome was significantly lower in patients who underwent laparoscopic appendectomy. The analysis of treating patients with acute appendicitis allows confirming that the introduction of laparoscopic appendectomy into the complex of surgical treatment of patients with acute appendicitis can significantly reduce the body’s response to stress from surgical trauma and pain, speed up recovery due to early activation of the patient and maximally reduce the duration of hospital stay, which definitely corresponds to the modern principles of fast-track surgery. Conclusions. The use of laparoscopic appendectomy makes it possible to significantly reduce the body’s response to stress from pain and surgical trauma and is an important part of the formation of the patient’s general condition. Complex surgical treatment of patients with acute appendicitis using non-invasive techniques allows shortening the duration of hospital stay (4.62 ± 0.77 days) and reducing the period of disablement. The method of minimally invasive surgical interventions can be considered a “gold standard” for providing medical care to the patients with urgent surgical diseases of the abdominal cavity, which provides an optimal approach to surgical treatment.

MULTIMODAL STRATEGY FOR THE MANAGEMENT OF SURGICAL PATIENTS(FAST TRACK SURGERY)

There was executed an analysis of the literature data on fast track surgery in foreign and domestic publications for the last 7 years, included in the database PubMed, Medline, Scientific electronic library (elibrary.ru). The review considers in details the principles of fast track surgery and the rationale for their use. The results of application of accelerated rehabilitation programs in surgical specialties are presented and analyzed. The use such programs allow shorten the duration of hospitalization, restore the patient’s ability to work in a more shorter time, without reducing the effectiveness of the treatment, which would have a positive economic effect. The implementation of the fast track surgery program requires a multidisciplinary approach of all specialists involved in perioperative management of the patient.

Role of pterygopalatine blockade in the early rehabilitation program of children after congenital cataract surgery

Nowadays, the surgical treatment of congenital cataract is a small-incisions surgery (aspiration, in some cases ultrasound phacoemulsification). It corresponds to the Fast Track surgery principles, and as a quick recovery technology it requires optimization of pain control in the early postoperative period. 
 Purpose. To estimate the efficiency of the pterygopalatine block as a component of an optimized Fast Track protocol in children after congenital cataract surgery.
 Materials and methods. 54 children operated for congenital cataract were included in the study. All patients were divided into 2 groups. In the first group (n = 26), a regional component of combined anesthesia on sevoflurane basis was carried out in combination with a pterygopalatine block; in the second group (n = 28), there was an implementation of a retrobulbar block. The efficiency of the methods was evaluated by a comparative analysis of hemodynamic parameters, the index of the vegetative system tension, the assessment of pain intensity by a verbal rating scale, as well as by the severity of ocular inflammatory reactions.
 Results. Obtained data show that the pterygopalatine ganglion block as a component of a combined anesthesia in congenital cataract surgery allows providing adequate anesthesia, creating prolonged pain control, reducing the inflammatory reaction in postoperative period during the first 24 hours.
 Conclusion. On the basis of our analysis, the possibility of a safe implementation of optimized (Fast-Track) protocol was proven.

OPPORTUNITIES OF LAPAROSCOPY IN THE TREATMENT OF ESOPHAGEAL ACHALASIA

The article describes opportunities and results of laparoscopic oesophagocardiomiotomy and laparoscopic transhiatal oesophagus removal without hand assistance in esophageal achalasia (cardiospasm). In total, such operations were performed in 196 and 31 of cases (of 423 patients), respectively. There were minimal numbers of relapses (below 2.3%) after laparoscopic oesophagocardiomiotomy done by the proposed technique. All cases of reflux esophagitis were diagnosed after esophagocardiomiotomy with Dor fundoplication.After cardiodilatation, disease relapses were registered in 57% of patients. The advantages of a laparoscopic access for oesophagectomy are shown and technical particular of this intervention are analyzed based on a case history. The principles of Fast track surgery in this patient category are discussed that allow for reduction of the length of hospital stay by 40%.

Introducing the fast track surgery principles can reduce length of stay after autologous breast reconstruction using free flaps: A case control study

Introduction: The concept of fast-track surgery (FTS) is a peri- and postoperative care concept developed to reduce length of hospital stay (LOS) and morbidity after surgery. FTS programmes have been reported from other surgical specialities, but there are few reports of FTS in plastic surgery. Materials and methods: Autologous breast reconstructions have been performed with abdominal free flaps since 1994. In 2006, an FTS program was introduced. Important changes in procedure were: early mobilisation, fewer/faster removal of drains and urinary catheter, discontinuation of epidural analgesia, planned early discharge, and multimodal opioid-sparing analgesia. The results from all unilateral, breast reconstructions in the first 5 years after the implementation of the FTS (n = 177) were compared to results prior to the FTS (n = 292). Flap type, operating time, blood loss and ischaemic time, LOS, early flap related and systemic complications (< 30 days) were analysed. Results: FTS significantly reduced mean LOS from 7.4 days to 6.2 days (p = 0.0002). When compared to pre-FTS results, similar flap types, operating time, blood loss and ischaemic time were found. LOS > 7 days were due to complications, the most common being haematoma. Prevalence of complications (6.5 vs 7.9%) and flap loss (2 vs 2%) did not increase. Haematomas seemed more frequent with the use of NSAID than with COX-2 inhibitors (9 vs 4%); however, the difference was not statistically significant. Conclusion: By introducing a simple, peri- and postoperative care concept it is possible to reduce LOS after microsurgery by at least 1 day without an increase in complications or flap loss.

Application of fast-track surgery principles to evaluate effects of atipamezole on recovery and analgesia following ovariohysterectomy in cats anesthetized with dexmedetomidine-ketamine-hydromorphone.

To evaluate the effects of atipamezole hydrochloride on recovery and analgesia following ovariohysterectomy in cats anesthetized with a dexmedetomidine hydrochloride, ketamine hydrochloride, and hydromorphone hydrochloride combination, in accordance with fast-track surgery principles. Prospective, randomized, clinical trial. 44 cats. Cats were anesthetized with a combination of dexmedetomidine (15 μg/kg [6.8 μg/lb]), ketamine (5 mg/kg [2.3 mg/lb]), and hydromorphone (0.05 mg/kg [0.023 mg/lb]), IM, supplemented with isoflurane in oxygen. Immediately after ovariohysterectomy, cats received meloxicam (0.2 mg/kg [0.09 mg/lb]) SC and either atipamezole (75 μg/kg [34.1 μg/lb]) or an equivalent volume of saline (0.9% NaCl) solution IM. Pain and sedation were scored at baseline (prior to surgery) and at predetermined intervals after surgery. Time to sternal recumbency was recorded. The atipamezole group recovered to sternal recumbency faster (median, 15 minutes; range, 5 to 60 minutes) than the saline solution group (median, 60 minutes; range, 15 to 90 minutes]). Pain scores did not differ between groups or at any time, compared with baseline, and were below the intervention threshold for most cats. Sedation scores were significantly greater in the saline solution group (median, 0; range, 0 to 2) at 2 hours after surgery, compared with the atipamezole group (median, 0; range, 0 to 0). Results indicated that administration of atipamezole, compared with saline solution, allowed for a faster recovery from anesthesia with dexmedetomidine-ketamine-hydromorphone in cats following ovariohysterectomy without compromising analgesia. These findings have implications for the provision of appropriate postoperative analgesia following ovariohysterectomy in cats.

Fast-Tracking Colostomy Closures.

There have been very few studies on applying fast-track principles to colostomy closures. We believe that outcome may be significantly improved with multimodal interventions in the peri-operative care of patients undergoing this procedure. A retrospective study was carried out comparing patients who had undergone colostomy closures by the fast-track and traditional care protocols at our centre. We intended to analyse peri-operative period and recovery in colostomy closures to confirm that fast-track surgery principles improved outcomes. Twenty-six patients in the fast-track arm and 24 patients in the traditional care arm had undergone colostomy closures. Both groups were comparable in terms of their baseline parameters. Patients in the fast-track group were ambulatory and accepted oral feeding earlier. There was a significant reduction in the duration of stay (4.73 ± 1.43days vs. 7.21 ± 1.38days, p = 0.0000). We did not observe a rise in complications or 30-day re-admissions. Fast-track surgery can safely be applied to colostomy closures. It shows earlier ambulation and reduction in length of hospital stay.

Value of fast track surgery principles in the perioperative management of liver cancer patients after hepatectomy

Objective To investigate the value of fast track surgery (FTS) principles in the perioperative management of liver cancer patients after hepatectomy.Methods Forty patients with primary liver cancer who were admitted to the First People's Hospital of Qinzhou from September 2011 to July 2013 were enrolled in this prospective study.All the patients were randomly divided into the FTS group (20 patients) and the control group (20 patients) according to the random number table.The perioperative management of patients in the FTS group was guided by the FTS principles,patients in the control group were managed with traditional methods.The intraoperative condition,time for portal occlusion,operation time,volume of intraoperative blood loss and blood transfusion,time to drainage tube removal,time to flatus and defecation,duration of postoperative hospital stay,expenses,changes of C-reactive protein on postoperative day 1,3,6,recovery of hepatic function and incidence of postoperative complications.All patients were followed up via phone call and out-patient examination till September 2013.All data were analyzed using the t test or chi-square test.The non-normal distribution paramenters were analyzed using the rank sum test.Results All patients were cured with no perioperative death.The time for postoperative drainage tube removal,time to flatus and defecation,duration of postoperative hospital stay and expenses were (2.3 ± 1.0)days,(2.5 ±0.5)days,(3.1 ±0.7)days,(7.0 ±0.8)days and (3.6 ±0.3) × 104 yuan in the FTS group,and (4.6 ± 0.7) days,(4.3 ± 0.7) days,(4.8 ± 0.4) days,(8.5 ± 0.9) days and (4.1 ± 0.3) ×104 yuan,with significant differences between the 2 groups (t =0.74,0.34,1.70,0.23,0.57,P ＜ 0.05).The levels of C-reactive proteins at postoperative day 1,3,6 were (56 ±7)mg/L,(122 ±7)mg/L and (35 ±7)mg/L in the FTS group,and (198 ± 24) mg/L,(137 ± 5) mg/L and (49 ± 8) mg/L,with significant differences between the 2 groups (F =64.91,P ＜0.05).The levels of prealbumin at postoperative day 1,3,6 were (196 ± 14) mg/L,(243 ± 17) mg/L,(260 ± 10) mg/L in the FTS group,and (198 ± 24) mg/L,(199 ± 16) mg/L and (245 ± 7) mg/L in the control group,with significant differences between the 2 groups (F =22.69,P ＜ 0.05).The levels of alanine transaminase at postoperative day 1,3,6 were (379 ±34)U/L,(166 ± 12)U/L,(49 ± 14)U/L in the FTS group,and (367 ±75)U/L,(210 ±28)U/L,(197 ±22)U/L in the control group,with significant differences between the 2 groups (F =4.51,P ＜ 0.05).One patient was complicated with peritoneal effusion and 1 with thoracic effusion in the FTS group; 4 patients was complicated with peritoneal effusion,3 with thoracic effusion,4 with pulmonary infection and 2 with incisional infection in the control group,with no significant difference in the complication between the 2 groups (x2 =0.78,1.11,4.44,2.11,P ＞ 0.05).All the patients were followed up for 2-24 months,no patients received reoperation or re-admitted to the hospital due to complications.Conclusion The application of FTS principle in the perioperative management of liver cancer patients after hepatectomy is safe and effective,it could alleviate the post-operative stress reaction and accelerate the recovery of liver function and patients' condition. Key words: Liver neoplasms; Hepatectomy; Fast-track surgery; Perioperative period

Standardising fast-track surgical nursing care in Denmark.

Considerable variations in procedures, hospital stay and rates of recovery have been recorded within specific surgical procedures at Danish hospitals. The aim of this paper is to report on a national initiative in Denmark to improve the quality of surgical care by implementation of clinical guidelines based on the principles of fast-track surgery-i.e. patient information, surgical stress reduction, effective analgesia, early mobilisation and rapid return to normal eating. Fast-track surgery was introduced systematically in Denmark by the establishment of the Unit of Perioperative Nursing (UPN) in 2004. The unit was responsible for guideline construction and implementation using the 'workshop practice method': establishing a website, creating a knowledge centre, coordinating implementation agents, and arranging national workshops and conferences. The UPN has promoted implementation of fast-track regimes in all surgical departments in Denmark. We recommend the workshop-practice method for implementation of new procedures in other areas of patient care.

‘23 h Model’ for breast surgery: An early experience

The principles of fast track surgery are well established in colorectal surgery. It is an evidence based model aimed at reducing length of stay, convalescence and morbidity by optimising both clinical and organisational factors. Despite this, the implementation of fast track surgery in breast cancer patients has been slow.The 23 h discharge model for breast cancer surgery patients has been outlined by the NHS Improvement Programme and is a breakthrough from traditional inpatient care. This paper outlines the early experience of implementation of this model in a single institution during a 3-month audit period. Over 80% of patients undergoing non-reconstructive breast surgery were discharged safely within ‘23 h’. This suggests that good communication links, reorganisation of existing resources, active user involvement (both patients and clinical team) and strong project management ensures fast-tracking to be safe for the patient with significant economic benefits for the hospital.

Fast-Track-Chirurgie - Voraussetzungen und Herausforderungen in der Nachbehandlung

In the last 15 years the Fast Track Concept or Enhanced Recovery after Surgery (ERAS) as a clinical pathway for improving perioperative care, maintaining physiological functions, reducing intraoperative stress and shortening the length of hospital stay, has become more common in colorectal surgery. After first promising results in prospective studies an expert group developed recommendations of a modified, multimodal Fast Track Concept in 2009. Main elements in this concept are laparoscopy, no nasogastric tubes, perioperative peridural anaesthesia and quick mobilisation of the patient after surgery. A metaanalysis in 2011 based on the Cochrane database showed, that in most studies regarding Fast Track Surgery, the authors have not strictly followed the recommendations of the expert group. Further studies with better quality and strict adaption on the multimodal principles of Fast Track Surgery are needed to gain more evidence. Furthermore the Fast Track Concept constitutes a challenge for the interdisciplinary collaboration of all involved treatment groups. Especially the postoperative outpatient treatment remains a problem due to unavailable rehabilitation capacities or ambulant care. Therefore a proper preoperative planning of the Fast Track Concept and the outpatient care should be performed interdisciplinary by the surgeons and the general practitioners.