Original article

doi:10.1111/j.1463-1318.2006.00995.x

Convalescence after colonic surgery with fast-track vs conventional care

D. H. Jakobsen*, E. Sonne, J. Andreasen and H. Kehlet*
*Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Section for Surgical Pathophysiology, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Department of Surgical Gastroenterology, Gentofte University Hospital, Hellerup and Unit of Medical Technology Assessment, Hvidovre University Hospital, Hvidovre, Denmark Received 9 May 2005; accepted 9 December 2005

Abstract
Objective To compare convalescence after colonic surgery with a fast-track rehabilitation programme vs conventional care. Background Introduction of a multimodal rehabilitation programme (fast-track) with focus on epidural anaesthesia, minimal invasive surgical techniques, optimal pain control, and early nutrition and mobilization together with detailed patient information have led to a shorter hospital stay after colonic surgery. There are not much data on convalescence after discharge. Methods A prospective, controlled, non-randomized interview-based assessment in 160 patients undergoing an elective, uncomplicated, open colonic resection or the Hartmann reversal procedure with a fast-track or a conventional care programme in two university hospitals. A structured interview-based assessment was performed preoperatively, and day 14 and 30 postoperatively. Results Patients undergoing colonic surgery with a fasttrack programme regained functional capabilities earlier with less fatigue and need for sleep compared with patients having conventional care. Despite early discharge of the fast-track patients (mean 3.4 days vs 7.5 days), no differences were found according to the need for home care, social care and visit to general practitioners, although the fast-track group had an increased number of visits at the outpatient clinic for wound care. More patients in the fast-track group were re-admitted, but the overall mean total hospital stay was 4.2 days vs 8.3 days in the conventional group. Conclusion A fast-track rehabillitation programme led to a shorter hospital stay, less fatigue and earlier resumption of normal activities, without the increased need for support after discharge compared with conventionally treated patients after uncomplicated colonic resection. Keywords Colonic surgery, fast track, perioperative care, convalescence

Background
Increased understanding of perioperative pathophysiology and the introduction of multimodal rehabilitation programmes with focus on epidural anaesthesia, minimal invasive surgical techniques, optimal pain control, and early nutrition and mobilization together with detailed patient information have led to a shorter hospital stay after colonic surgery [1,2]. The reasons are that these approaches reduce the stress responses and organ dysfunctions, and therefore lead to a quicker recovery with a

Correspondence to: Dorthe H. Jakobsen, Section of Surgical Pathophysiology, 4074, Rigshospitalet, The Juliane Marie Centre, 2100, Copenhagen, Denmark. E-mail: dorthe.hjort@rh.dk

reduction in morbidity [35]. These rehabilitation programmes are also called fast-track surgery, because the discharge criteria are obtained earlier compared with conventional care. Several studies have revealed the benets of fast-track programmes. Organ functions, muscle mass and strength, and physical performance are not deteriorated compared with the preoperative level and the duration of ileus is reduced from about 4 days to 12 days [69]. However, not much data are available on symptoms and function after the early discharge [10]. The aim of this study was therefore to compare convalescence after colonic surgery with a fast-track multimodal rehabilitation programme vs a conventional care programme. Focus was on fatigue, need for sleep,

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instrumental activities of daily living, (IADL), basic activities of daily living (BADL), need for social and home care, contact with general practitioners, and readmission rate.

Table 2 Demographic pre- and postoperative data in patients undergoing fast-track multi-modal rehabilitation vs conventional care and excluded patients Fast-track Conventional group group (n 80) (n 80) Age (years) Sex (M:F) Postoperative hospital stay (mean/median) days Total postoperative hospital stay inclusive readmission (mean), days Preop. leisure time activity (n) Preop. work (n) Living alone (n) Type of surgery Right resection Left resection Transverse resection Sigmoid resection Hartmann reversal Recto-sigm. resection Excluded patients Change in surgical procedures (low anterior resection or stoma) Acute surgery Anastomotic leak Reoperated (bleeding) Bleeding gastric ulcer Myocardial infarction *P < 0.01. 68 42:38 3.4/2* 4.2* 74 21 34 28 3 1 37 7 4 n 15 6 1 5 2 1 69 37:43 7.5/7* 8.3* 74 16 33 51 1 2 25 1 0 n 19 14 1 3

Patients and methods

The study was based on a prospective, controlled, nonrandomized interview-based assessment in 194 patients undergoing elective, open colonic resection or the Hartmann reversal procedure. Ninety-ve consecutive patients admitted to Department of Surgical Gastroenterology, Hvidovre Hospital, between January 2000 and December 2002 (except July) who followed a fast-track programme (Table 1) and 99 consecutive patients admitted to the Department of Surgical Gastroenterology, Gentofte Hospital, between February 2000 and April 2000, and September 2000 and February 2003 (except July) who followed a conventional care programme with no well-dened criteria for use of nasogastric tubes, mobilization and oral uid and nutrition or planned hospital stay were included in the study. Both groups received combined general anaesthesia and epidural analgesia. Exclusion criteria were change of operative procedure or patients receiving a stoma. Furthermore, patients with major complications were excluded, as the study aimed at describing the postoperative convalescence after uncomplicated colonic resection. Thus, 15 patients were excluded in the fast-track group and 19 patients in the conventional care group (Table 2). Sixty of the 160 patients were included in a previous preliminary study [10]. A structured interview-based assessment was performed preoperatively, and on days 14 and 30 postoperatively. On day 14, an interview was conducted
Table 1 Care programme in patients undergoing colonic resection with fast-track care Preoperatively Information of surgical procedure, expected length of stay and daily milestones for recovery Mobilized 2 h Drink 1 l 2 protein-enriched drinks Solid food Mobilized > 8 h Drink > 2 l 4 protein enriched drinks Solid food Remove bladder catheter Plan discharge Normal activity Remove epidural catheter Discharge after lunch

Day of surgery

Postoperative day 1

Postoperative day 2

during home visits of patients in both groups. On day 30, patients in the fast-track group were interviewed in the outpatient clinic, while the patients in the conventional care group were interviewed at home. Fatigue was measured on a verbal scale (0 no, 1 less, 2 moderate and 3 severe fatigue) and need for sleep during daytime and night was assessed in hours per day. Activity of daily living was measured as the need for personal care (BADL) and as the ability to perform physical activities (IADL). BADL was scored as the need for care according to mobility, personal hygiene, dressing, eating, sensory functions, overall activity, urinary and gastrointestinal functions, social integration, and psychiatric support on a four-point scale (0 no need for care, 4 total compensated care, maximum score 36 describing total dependency of care). All activity scores have been validated before in geriatric patients [11]. IADL was assessed by means of being able to walk outdoors, walking stairs, cooking, housekeeping, car driving and shopping on a 01 scale (0 no, 1 yes, maximum score 6). Time until resumption of preoperative

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leisure-time activity and job was assessed together with the reason for not resuming normal activity. Need for home care and social care were assessed on a 01 scale (0 no, 1 yes). Visits to general practitioners and unplanned contact to the outpatient clinic were assessed within the rst month regarding numbers of visits and reasons. Readmissions during the rst month were recorded. There was a 30-day postoperative followup in all 160 patients. For statistical analysis, we used the MannWhitney, Friedman, Fischers exact and chi-squared tests, where appropriate. Data were specically analysed on day 14. In addition, inter- and intragroup comparison was performed for the entire study period by variance analysis. The study was explorative and sample size calculation was not performed. P < 0.05 was considered to be signicant.

Results
Patient demographics was similar in the two groups according to age, sex and number of patients with preoperative leisure-time activities, but length of stay was a median of 2 days in the fast-track group vs 7 days in the conventional care group (P < 0.01). More patients in the fast-track group were working preoperatively (21 vs 16 in the conventional group). More patients had a left-sided resection in the fast-track group (Table 2). Basic activities of daily living was constant in both groups (P > 0.05) without differences between groups during the entire study period (data not shown). IADL decreased in both groups on day 14, but signicantly more in the conventional care group, despite having a higher preoperative IADL level compared with the fasttrack group (Table 3). Preoperative fatigue was not
Table 3 Convalescence after colonic resection with fast-track vs conventional care

different between groups, but on day 14 fatigue was signicantly increased in the conventional care group compared with the fast-track group without differences on day 30 (Table 3). Total length of sleep was increased signicantly from 8.5 h preoperatively to 9.6 h on day 14 in the conventional care group. In contrast, the fast-track group had no change in the need for sleep 14 days postoperatively compared with preoperatively (8.1 h vs 8.8 h, P > 0.05). Six of 21 patients in the fast-track group and six of 16 patients in the conventional group had not started to work again on day 30 (P > 0.05 between groups). The main reasons for not resuming work were wound infection and waiting for chemotherapy (not shown). Seventy-four patients in each group had leisure time activity preoperatively. On day 14, 23 patients in the fasttrack group vs 47 patients in the conventional group had not resumed leisure time activity (P < 0.05). The main reasons for not resuming activity in the conventional group were that 12 patients had either just been discharged or were still hospitalized, and furthermore fatigue was a major problem. There was no signicant differences between groups according to the number or reason for contact to general practitioners within the rst 14 days and between day 14 and day 30. Thirteen patients from the fast-track group vs six patients in the conventional group had an unplanned visit in the outpatient clinic, mostly because of wound infection. No difference between groups was found between day 14 and day 30. Signicantly more patients in the fast-track group, 16 vs eight patients in the conventional group, were readmitted within 30 days postoperatively (P < 0.05). Reasons for re-admission are shown in Table 4. The

Preoperatively

Day 14

Day 30

IADL (walking outdoor, walking stairs, cooking, cleaning, shopping, car driving) Fast-track group (n 80) 4.7 3.8* 4.4 Conventional group (n 80) 5.1 3.5* 4.6 Fatigue mean Fast-track group (n 80) 2.1 1.7 2.0 Conventional group (n 80) 2.3 2.9* 2.5 Sleep duration mean (h) Preoperatively (day/night) 0.5/7.6 0.5/8.0 Day 14 (day/night) 0.9/7.9 1.2/8.4* Day 30 (day/night) 0.6/7.6 1.1/8.0

Fast-track group (n 80) Conventional group (n 80)

Instrumental activities of daily living (IADL) (not able 0, able 1, max. score 6) Fatigue (0 no, 1 mild, 2 moderate, 3 severe); sleep duration at daytime and night. *P < 0.01 preoperative vs day 14.

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Fast-track group (n 80) Social care support Preoperatively Day 14 Day 30 Home care support Preoperatively Day 14 Day 30 Re-admissions within 30 days postoperation

Conventional group (n 80)

Table 4 Need for social care and home care support pre- and postoperatively and numbers of readmissions.

16 17 18 1 12 15 Wound infection 5 Urinary tract infection 3 Rectal bleeding 1 Defecation problem 3 Fever 1 Death of the husband 1 Preexisting cardiac disease 1 Sick from chemotherapy 1

12 13 18 1 9 13 Wound infection 4 Vomiting 2 Anastomotic 1

total hospitalization was still signicantly lower in the fast-track group (mean 4.2 days vs 8.3 days) (Table 2). The pre- and postdischarge need for social support and nursing care was similar between the groups (Table 4).

Discussion
The present study demonstrates that patients undergoing colonic surgery with a fast-track programme regain functional capabilities earlier and with less fatigue and need for sleep compared with patients having conventional care. The largest difference between groups was on day 14 postoperatively, where fatigue was the main reason for not resuming instrumental activities of daily living and leisure time activity. These results support our previous preliminary ndings in a subgroup of the present study in patients undergoing fast-track colonic resection [10]. In spite of the early discharge of the fast-track patients, no differences were found according the need for home care, social care and GP visits, although the fast-track group had an increased number of visits at the outpatient clinic mostly for wound care. The increased problems with wound infections in this small study were not found in a previous large consecutive study with 260 patients from the same two departments [9]. Furthermore, more patients in the fast-track group were re-admitted but the total mean hospital stay was still lower (4.2 days vs 8.3 days) compared with the conventional care group. As the fast-track programme was experimental and with a short hospital stay, the fast-track team had a tradition for readmission, if the patient called the ward with the following symptoms: fever, abdominal pain and vomiting, to make sure that no serious compli-

cations were with delayed diagnosis after discharge. Although the readmission rate was 19% the reasons for readmission mostly were due to minor complications, and observation [9]. In other centres with fast-track colonic surgery programmes, a lower readmission rate has been observed [12]. We excluded patients with major complications as this study aimed at describing the postoperative convalescence after uncomplicated colonic resection. In this context, a previous large study showed that a fast-track programme decreased medical complications, while surgical complications such as anastomotic leakage and wound problems were similar [9]. The demonstrated shorter convalescence with a fasttrack rehabilitation programme is in accordance with other studies to demonstrate earlier normalisation of paralytic ileus, oral intake, cardiovascular response to exercise, muscle force and lean body mass [69]. In conclusion, this prospective, controlled, non-randomized interview-based study showed that a fast-track rehabillitation programme with focus on optimal pain control, early nutrition and mobilization and a detailed patient information led to a shorter hospital stay after uncomplicated colonic surgery. Furthermore, convalescence was reduced with earlier resumption of normal activities, with reduced fatigue and without increased need for support compared with conventionally treated patients.

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