Comment on "Does a Combination of Laparoscopic Approach and Full Fast Track Multimodal Management Decrease Postoperative Morbidity?"

To the Editor:

We read with great interest the article by Le’on Maggiori et al.[1] In order to assess the postoperative outcomes of combination of laparoscopic approach and full fast track multimodal (FFT) management, the authors assigned patients with colorectal cancer into 2 groups: FFT and LFT (limited fast track program), the latter of which was established as a control. No differences in length of stay (LOS) or postoperative morbidity were, however, obtained between the 2 groups in that study.

The fast track (FT) care program, also known as Enhanced Recovery After Surgery (ERAS) program, is a multimodal approach that aims to minimize the physiologic impact of surgery and anesthesia.[2] As recommended by several guidelines with regard to clinical practice of ERAS protocol in perioperative management, there are 15 to 25 recommended items that might contribute to the improvement of clinical outcome.[3-5] The relative significance of each element, however, remains unknown because of the lack of definitive support from evidence-based medicine.[6] Moreover, the complete implementation of all these recommended items, which could result in the poor compliance of patients, is very unrealistic in clinical practice among most of the surgical world.

Generally speaking, the ERAS program for gastrointestinal surgery consists of the following essential components in postoperative recovery phase: early oral feeding, early mobilization, multimodal analgesia, limited perioperative fluid infusion, discard of nasogastric tube and minimally invasive surgery,[7] and mostly included in the study,[1] although no exact data on total fluid administration on day 0 were presented.

It was found that the difference of postoperative morbidity, mortality, and theoretical and effective LOS between the 2 groups was not of significance neither regarding the overall cohort, nor in the colon or rectal cancer subgroups.

In addition, the authors have pointed out that a full multimodal FT care program had no benefit in patients with rectal cancer, which was attributed to the routine use of a diverting stoma. It was suggested in that article that an FT care program had limited benefits in patients with temporary diverting stoma. The role of fecal diversion using a diverting stoma in anterior rectal resection and anastomosis is, however, still controversial at present.[8] Gumbau et al[9] reported that the association of a loop ileostomy and multimodal FT care program did not extend the LOS nor increases the rate of complications in patients that underwent a rectal resection with anastomosis. The most important problem with the article is, however, the reported long LOS (approximately 8 days in the colonic cancer subgroup and approximately 10–11 days in the rectal group), which is impossible to interpret in relation to the information about the FFT programs, both regarding the theoretical LOS and the effective LOS. Also, the LOS is much longer than reported in other FFT series with full implementation.[10,11]

Consequently, the application of the essential elements of ERAS protocol combined with laparoscopic technique in colorectal cancer surgery obviously is appropriate, but interpretation of such studies requires detailed information not only about the components and compliance with the FFT program, but also information “Why in hospital?” when LOS is longer than reported in other fully implemented FFT programs.