Fast-track in abdominal aortic surgery: experience in over 1,000 patients.

BACKGROUND: Fast-track recovery programs have led to reduced patient morbidity and mortality after surgery. Minimally invasive surgery and anesthesia, with programs of early postoperative recovery are the main aspects of fast-track recovery programs. The optimization of pain control, early mobilization, and oral feeding allows for a rapid functional rehabilitation, which leads to minor morbidity and early discharge from the hospital to home. METHODS: We enrolled all nonemergent patients treated for elective abdominal aortic surgery for an aneurysm or obstructive disease from April 2000 to June 2014. The fast-track protocol was applied to all these patients. A transperitoneal aortic approach was used through a left subcostal incision and was complemented with epidural anesthesia-analgesia and a protocol of early rehabilitation. RESULTS: A total of 1,014 patients were treated for elective aortic surgery. For 980 patients (96.6%), clear liquids followed by a semisolid diet were tolerated starting on the afternoon of the day of intervention (day 0). Nine hundred eighty-seven patients (97.3%) began early ambulation on day 0, and for 81.2% of the population, regular colonic function returned within the second postoperative day. Seventeen deaths (1.7%) occurred. Nine hundred ten patients (89.7%) had no complications. The median hospital length of stay was 3 days for the entire series, and 80.4% of patients (n = 815) were discharged to their homes between the second and fifth days after surgery. CONCLUSIONS: The fast-track program can be efficiently and safely applied to aortic surgery and that this program improves surgical outcomes, allows for earlier discharge, and reduces costs.

Fast-track approach in abdominal aortic surgery: left subcostal incision with blended anesthesia.

OBJECTIVES: The introduction of fast-tracking multidisciplinary programs allows good results in postoperative outcome in many surgical specialties. We evaluated a multimodal clinical program (based on mininvasive surgery, epidural anesthesia and early mobilization and feeding) in abdominal aortic surgery. METHODS: Between June 2000 and October 2005, 323 unselected patients were treated for atherosclerotic aorto-iliac occlusive disease (aorto-femoral bypass) and aortic or aorto-iliac aneurysm (aorto-aortic graft or aorto-iliac bifurcated graft). The infusion of bupivacaine 0.5% through an epidural catheter at T6-T7 interspace allowed sensory block between T4-S3. A light general anesthesia was performed using sevoflurane by a laryngeal mask in spontaneous breathing; no nasogastric tube was used. The patients were placed in dorsal decubitus; a transperitoneal access was performed with a left subcostal incision parallel to the condro-costal edge and spread from the linea alba to the edge of the rectus muscle. The bowel was maintained inside the abdominal cavity and manipulated with care. Standard surgical instrumentation was used. No drains were placed. Patients were transferred to the surgical ward at the end of surgery; they were early mobilized and enforced to drink and to eat. Analgesia was achieved with a continuous epidural infusion of bupivacaine 0.25% supplemented by oral ibuprofen on request. RESULTS: We observed a mortality rate of 2.5% and a low postoperative morbidity: 1.4% of cardiac complications, 3.7% of transient creatinine increase, and no pulmonary complications. All patients ambulated a mean of 536 m (95% CI: 81.4) on the day of surgery and 2544 m (95% CI: 208.9) the day after. They consumed an oral diet, 36.2% of their daily caloric requirement on the same day of surgery and 1583 Kcal (95% CI: 105.2) the day after (77% of daily caloric requirement). Median hospital stay was three days (range 2-21). All patients were discharged home. CONCLUSIONS: Our experience suggested that hospital stay and morbidity after abdominal aortic surgery can be decreased by performing a mininvasive surgical approach, thoracic epidural anesthesia-analgesia and an aggressive postoperative nursing on the ward. Therefore, this multidisciplinary program can be proposed to all patients undergoing aortic surgery without prior selection, major technological investments and long-term surveillance.