Evidence-based surgical care and the evolution of fast-track surgery.
BACKGROUND
Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.


OBJECTIVE
To assess, synthesize, and discuss implementation of "fast-track" recovery programs.


METHODS
Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work.


RESULTS
Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology.


CONCLUSIONS
Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.
Kehlet
Henrik
H
Section of Surgical Pathophysiology 4074, Rigshospitalet, Copenhagen, Denmark. henrik.kehlet@rh.dk
Wilmore
Douglas W
DW
D019317:Evidence-Based Medicine / Q000592:standards / Q000639:trends; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006801:Humans; D007902:Length of Stay / Q000639:trends*; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000379:methods / Q000639:trends*; D010147:Pain Measurement; D017060:Patient Satisfaction; D011182:Postoperative Care; D011183:Postoperative Complications / Q000517:prevention & control*; D011787:Quality of Health Care; D020127:Recovery of Function; D012042:Registries; D012680:Sensitivity and Specificity; D013514:Surgical Procedures, Operative / Q000379:methods* / Q000639:trends; D013997:Time Factors