Fast-track concepts in major open upper abdominal and thoracoabdominal surgery: a review.

INTRODUCTION: The purpose of this article was to review the research considering fast-track concepts in upper abdominal and thoracoabdominal surgery.
METHODS: A search for clinical studies evaluating the fast-track concept after open major upper abdominal or thoracoabdominal surgery was performed. Reference lists of identified articles were searched. Trials-written in English-that compared a concept and traditional care were evaluated with regard to their internal validity. Level of evidence was defined and each outcome was evaluated.
RESULTS: In total, 15 articles were found, separated into gastric (n = 2), pancreatic (n = 5), hepatic (n = 2), esophageal (n = 3), and aortic surgery (n = 3). Three were randomized, controlled trials. The different trials represented various concepts of fast-track surgery, but the majority included specific programs for analgesics, avoidance of drainage tubes, early start of oral nutrition, and early and active mobilization. There is moderate evidence that fast-track concepts result in shorter hospital stay. There is low evidence that fast-track concepts shorten need of ventilation, decrease the need of care at the intensive care unit, decrease postoperative pain, and reduce total hospital costs. The concepts seem to have similar rates of surgical complications, readmission rate, and mortality rates as conventional care. No specific adverse events were reported.
CONCLUSIONS: Although the methodological quality of the articles reviewed was low and the trials heterogeneous, all trials concluded that the introduction of fast-track concepts were safe and feasible, achieved shorter hospital stays, and reduced costs. Future randomized, controlled trials are needed to further evaluate the effect of these concepts.