O. Ioffe, O. Stetsenko, T. Tarasiuk, M. Kryvopustov

Bogomolets National Medical University, Kyiv, Ukraine

ABSTRACT. Relevance. Fast Track surgery concept provides for a significant reduction of patient’s stress response to surgical intervention. The main task is a quick rehabilitation, quick return to a normal quality of life and significant reduction for an in-patient stay, thereby reducing medical costs.

Objective: To assess the efficacy of the lack of pre- and postoperative fasting in accelerating postoperative recovery of patients and the reduction of patient’s stress response to operative injury.

Materials and methods. We performed 564 surgical interventions under Fast Track approach. In particular, we used adapted, high-caloric sipping (drinking as small sips through a straw) feed manufactured at a medical enterprise and does not include dietary fibre — Nutricomp Drink Plus (BBraun).

Results. Early oral feeding within the first hours after surgery accelerates recovery of productive intestinal motility. In 73.5 % of patients, the passage of flatus (spontaneous) is reported to the end of the first postoperative day that is about 8-fold higher than in patients who were not on such diet. General weakness, hunger and thirst reduced 2.5, 3 and 2.5-fold, respectively, in patients on Fast Track approach compared with the conventional perioperative management.

Conclusion. The lack of pre- and postoperative fasting is one of the cornerstones of this program that proved the efficacy in terms of reduced stress response to surgical injury.

Key Words: Fast Track approach, surgical intervention, pre- and postoperative nutrition.

Relevance. At the edge of ХХ–ХХІ century, the concept of Fast Track surgery has appeared. This trend was initiated and now is developed by the Professor Henrik Kehlet (Denmark). This concept means complete breaking-down of the conventional perioperative management of the patients. Although it has been almost 20 years passed after first attempts in the implementation of these principles, in Ukraine it is not possible yet to implement new approaches in management of surgical patients completely.

Fast Track surgery concept provides for a significant reduction of patient’s stress response to surgical intervention. The main task is a quick rehabilitation, quick rerun to a normal quality of life and significant reduction for an in-patient stay, thereby reducing medical costs.

Factors influencing patient’s stay in the hospital 24 hours after surgery were analysed, namely: pain (30%), dizziness (20%), weakness (15%), patterns of workflow management (20%). In 48 hours: pain (10%), dizziness (20%), weakness (25%), patterns of workflow management (20%) [1].

The task of Fast Truck surgery is the significant reduction in the negative aspects during the postoperative period via reduction of the body stress response to the surgical intervention. The range of measures includes modified preoperative preparation, as well as the reduction of injury during the surgery.As the response to surgery, the central nervous system starts to produce inflammatory mediators and different stress hormones [5,7], which results in insulin resistance during the early postoperative period, and this is the cause of delayed postoperative recovery and longer in-patient stay. Manifestations of the stress response in the postoperative period are as follows: pain, catabolism, immune dysfunction, nausea/vomiting, GI paresis, respiratory impairment, increased cardiac demand, coagulation and fibrinolytic dysfunction, CNS dysfunction, impaired water balance, disturbed sleep, rapid fatigability. H. Kehlet [4,6] formed ways to reduce the above manifestations:

· minimally invasive intervention (lesser surgical injury — lesser pain impulses in the early postoperative period);

· pharmacological support: NSAIDs, paracetamol, antiemetics, glucocorticoids, ß-blockers, ɑ2-agonists, anabolics, nutrition, local anaesthesia;

· afferent neural block: local infiltration anaesthesia, regional anaesthesia, neural block;

· other variants: Prevention of intraoperative hypothermia, optimization of pre- and intraoperative infusion, preoperative carbohydrate diet, early oral nutrition.

At the Chair of Surgery, these principles have been implemented in a daily routine of the surgical clinic since 2011. One of the most important and challenging processes was preoperative and early postoperative nutrition. Since over 100 years, conventional management of a surgical patient involved pre- and postoperative fasting.

Objective: To assess the efficacy of the lack of pre- and postoperative fasting in accelerating postoperative recovery of patients and the reduction of patient’s stress response to operative injury.

Materials and methods. From September 2011 to September 2018, we have performed 564 surgical interventions under Fast Track approach (Fig. 1).

All the patients received 200 mL of warm boiled water with 5 g glucose not later than 2 hours before surgery.

Fig. 1. Distribution of surgical interventions performed under Fast Track surgery principles

This allows reducing fasting period, hunger and thirst, as well as fear of surgery, reduces the risk of insulin resistance after surgery, in particular during induction anaesthesia (risk of regurgitation), since within 2 hours this liquid completely empties the stomach [2,3]. Insulin resistance is the body response to fasting (survival via retention of protein) [3,7].

Furthermore, consumption of carbohydrates increases the anabolic effect in the early postoperative period, in particular, there is a reduction in nitrogen level and loss of protein in this period, postoperative body weight and muscular function are maintained [2,3,5].

When the above principles were implemented in the process of the surgical department for the first time, the selection of high-caloric postoperative nutrition was a complex stage. As recommended in the majority of studies, the main requirements to the products are as follows: their liquid state, high caloric value, complete absorption in the proximal GI segments [8].

We opted for adapted high-caloric sipping (drinking as small sips through a straw) feed manufactured at a medical enterprise and does not include dietary fibre. Nutricomp Drink Plus (BBraun) complied with such criteria among products in the Ukrainian market. The composition of this mixture is provided in Table 1.

Table 1

Composition of Nutricomp Drink Plus (BBraun)

Average content per 100 mL: Na 100 mg, К 170 mg, Са 72 mg, Mg 27 mg, Р 60 mg, СI 115 mg, Fe 1.7 mg, Zn 1.2 mg, Сu 170 µg, І 25 µg, Сr 16 µg, F 0.15 mg, Мn 0.58 mg, Мo 12 µg, Se 8.3 µg, vitamin A (RE) 147 µg, vitamin D 1.8 µg, vitamin Е (α ТЕ) 2.0 mg, vitamin K 12 µg, vitamin В₁ 0.18 mg, vitamin В₂ 0.22 mg, vitamin В₆ 0.22 mg, vitamin В₁₂ 0.55 µg, vitamin С 15 mg, niacin (NE) 2.4 mg, folic acid 45 µg, pantothenic acid 1.1 mg, biotin 8.0 µg, choline 30 mg. Osmolality 470 mosmol/L, water 76 mL/100 mL.

To assess the effect of early oral nutrition on the course of the postoperative period, we have formed 2 groups of patients matched by the age and gender (р > 0.05) — experimental and control group, where laparoscopic interventions were performed due to cholelithiasis. Informed consent for participation in the study and authorization form in terms of personal data about health condition was obtained from all patients.

Group 1 (control) included 34 patients who were allowed to consume only water (up to 100 mL) 6 hours after surgery as per the conventional method of management in the early postoperative period. Group 2 (experimental) enrolled 34 patients who were allowed to consume Nutricomp Drink Plus (to choose from vanilla and chocolate flavours) 4 hours after surgery at an amount of 200 mL. The assessment was performed the next day after surgery according to criteria in Table 2.

Table 2

Questionnaire for subjective assessment of patient’s condition at the first postoperative day

Note: figures are the assessment of subjective patient’s sensation from 1 to 10, where 1 — the lowest intensity of manifestations, 10 — the highest intensity.

After the obtained results of the study of the effect of preoperative carbohydrate load and early postoperative sipping nutrition on patients’ condition after laparoscopic cholecystectomy — all other patients who underwent surgery with the implementation of Fast Track program received nutrition somewhat modified depending on the type of surgery. In case of surgeries that did not include the formation of gastrointestinal anastomosis (laparoscopic intraperitoneal hernioplasty, laparoscopic appendectomy, laparoscopic resection of the colon), pre- and postoperative regimen of early nutrition was similar to the regimen used at the first stage of our study. In case of surgeries due to morbid obesity (laparoscopic gastric bypass), where the gastrojejunal anastomosis is formed, postoperative nutrition regimen was changed: the first sipping oral nutrition was given 10–12 hours after surgery. This is due to the placement of nasogastric tube for decompression and control (monitoring of possible gastric bleeding from anastomosis) during 24 hours. In the patients, who underwent surgery in the setting of Fast Тrack program, further after the study we have established similar parameters using questionnaires (Table 2).

Results and their discussion. At the first stage of our work, we have performed an analysis of parameters in the experimental and control group in the case of laparoscopic cholecystectomy (Table 3).

Table 3

Comparison of questionnaire parameters between experimental and control group

Note: data are provided as M±SD or abs. (%).

Use of pre- and postoperative nutrition positively influences the main complaints of patients, namely — there was a significant reduction in early postoperative nausea/vomiting: 64.7% in the control group, 17.6% in the experimental group (Р< 0.001). Hunger on the first day after surgery was registered in 6,03 ± 1.75 patients in the control group and in 1.97 ± 0.63 (Р < 0.001) patients in the experimental group. Thirst — 5.94 ± 1.50 in the experimental, and 2.44 ± 1.16 (Р < 0.001) in the control group. Natural early postoperative nutrition also contributes to a rapid recovery of productive motility of the intestine. Passage of flatuses on the first day after surgery was reported in 73.5% of patients from the experimental group, as opposed to only 8.8% in the control group (Р < 0.001). At the same time, the effect of early oral nutrition on a stool at the first day after surgery was not registered in both groups.

Use of Fast Тrack approach, namely multimodal analgesia in the perioperative period in combination with preoperative oral carbohydrate load and early return to oral nutrition with adapted mixtures significantly influences the level of pain impulses at the first day after surgery. While patients of the control group evaluate their pain as 6.26 ± 1.52 by VAS, then in the experimental — 2.74 ±.1.05 (Р < 0.001).

General weakness is one of the main factors of prolonged in-patient stay after surgery. During the evaluation of this parameter in the control group, we have obtained 6.47 ± 1.26 points, and in the experimental — 2.26 ± 0.86 (Р < 0.001). Depressive conditions in the first days after surgery are the consequences of all of the above complaints and sensations. In the control group, this parameter was 4.79 ± 1.07 points on average, while in the experimental — 1.50 ± 0.86 (Р < 0.001). Further, this regimen of perioperative nutrition was unchanged for laparoscopic cholecystectomy.

Results from questionnaires in other groups of patients are provided in Table 4.

Table 4

Comparison of questionnaire parameters in other groups of patients

When pain impulses were compared on the first day after surgery in all patients, they were virtually the same. This may suggest the efficacy of multimodal analgesia in Fast Тrack approach. Nausea in 40.21% of patients after laparoscopic gastric bypass call attention and this may be associated with nasogastric tube. Bloating was the most common on Day 1 in 30.31 patients after laparoscopic hernioplasty. This predominantly may be due to the previous viscerolisis to prepare a site for mesh implantation. Hunger and thirst (5.34 and 4.38, respectively) are the most common in patients after laparoscopic gastric bypass, that may also be due to the nasogastral tube and the lack of early oral nutrition at Day 1. Stool at Day 1 in 62.96% patients after laparoscopic resection of the intestine is the consequence of the formation of mechanical anastomosis, use of peridural anaesthesia and anal divulsion. General weakness at the first day after the intervention is not critical, however, it is slightly higher in patients after laparoscopic gastric bypass, who solely did not receive early oral nutrition at the first postoperative day.

Conclusion. The obtained data suggest a direct interaction between the reduction of stress response to the surgical intervention and implementation of Fast Тrack principles in the surgical department. Nutrition of the patient before surgery and early return to oral natural nutrition directly after surgery plays one of the key roles in the quick recovery of the patient and reduction in manifestations of stress response to surgical intervention. Why preoperative fasting is necessary? Indeed, when stomach functions normally, its content is eliminated within 2 hours and there is no risk of regurgitation during initiation and conduct of general anaesthesia. Furthermore, when patients consume saturated carbohydrate mixture 2–3 hours before surgery, this contributes to an increase in energy stocks of the body and reduces postoperative insulin resistance as the manifestation of the stress response. When early oral nutrition is started within the first hours after surgery, it accelerates the recovery of productive intestinal motility. For example, in 73.5% of patients, the passage of flatus (spontaneous) is reported to the end of the first postoperative day that is about 8-fold higher than in patients who were not on such diet. General weakness, hunger and thirst reduced 2.5, 3 and 2.5-fold, respectively, in patients on Fast Track approach compared to the conventional perioperative management.

Certainly, it is no easy to change conventional believes in the surgical world. However, based on a huge base of evidentiary medicine at the current stage of development of healthcare and orientation of surgery to a quick recovery of patients after surgery, we should accept the efficacy of implementation of Fast Тrack principles in the surgical departments of Ukraine. The lack of pre- and postoperative fasting is one of the cornerstones of this program that proved efficacy in terms of reduced stress response to surgical injury.

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Надійшла до редакції 15.08.2019 р.