|Interview to Mr. A. Williams|
"Laparoscopic surgery on its own will reduce length of stay when there are no complications. Laparoscopic surgery within an enhanced recovery service may not reduce the length of stay over and above that achieved with open surgery, however it does make enhanced recovery easier to achieve."
Mr. A. Williams is a consultant colorectal surgeon at St Thomas’ and Guy’s Hospitals, and the Director of the Pelvic floor unit.1. Could you give us some words about yourself?
I am a consultant colorectal surgeon at St Thomas’ and Guy’s Hospitals, I am also the Director of the Pelvic floor unit. I have special interests in Enhanced Recovery Programs and the optimisation of the care of patients undergoing colorectal surgery. I also have special interest in pelvic floor pathology and proctology including anal fistulae.
2. When would you establish your first interest on Enhanced recovery surgery?
I first started looking at Enhanced Recovery in 2005 and started our program in October 2006
3. According to your experience, what should be the main objective of any Fast Track program?
To minimise morbidity following surgery and optimise recovery, in so doing to reduce length of stay without compromise of discharge criteria.
4. Are all patients candidates for Fast Track?
YES, those with most co-morbidity and having the largest operations have the most to gain.
5. Among the different steps that usually forms the enhanced recovery programmes, which one do you think are the more important?
Of major importance is education and expectation management, without this any hopes of earlier discharge fails. With this come nutrition and shorter fasting periods, preop carbohydrate loading and the avoidance of bowel prep. Goal directed fluid management in the peri-operative period is also very important.
6. Most fast track programmes have among their steps the optimization of fluid therapy, could you explain, in short, what this mean?
Fluid optimisation involves an accurate beat to beat assessment of intravascular filling. In response to this fluid is given and the physiological response measured. If it is evident that the intravascular system is still under filled then more fluid is given until the system is filled. Only when the response to filling changes can one consider the intravascular system full. By reassessing fluid can be given when needed.
7. On average how much faster would a patient who has had fast track surgery be at home, compared to one who’s had traditional surgery?
Usually we would expect between 3 and 7 days sooner.
8. Talking about laparoscopic colorectal surgery, if a patient has laparoscopic surgery but out of any fast track protocol does it have the same benefits?
Laparoscopic surgery on its own will reduce length of stay when there are no complications. Laparoscopic surgery within an enhanced recovery service may not reduce the length of stay over and above that achieved with open surgery, however it does make enhanced recovery easier to achieve.
9. According to your Enhanced recovery programme, what are your criteria of exclusion?
NONE other than the patient refusing to mobilise, eat etc.
10. How difficult is to establish a Fast track programme?
It is moderately difficult to start, mainly because of the need to constantly remind everyone involved about what is needed, and to encourage constant questioning of why a patient cannot eat, have lines out, remove catheters etc?
What is more difficult is maintaining momentum in the long term especially as junior staff but medical and nursing change.
11. Talking about cost, are these programmes cost-effectives?
Reducing length of stay by even 1 – 2 days immediately makes the program cost effective. Most of the steps involved in the Program cost very little, what needs to change is expectation and old preconceptions of surgical management.
12. It is assumed that Fast Track programmes are a number of evidenced–based interventions to improve both care and recovery. Why they are so difficult to be worlwide accepted?
Reluctance of adopting Fast Track recovery is largely due to “traditional” surgical teaching and mentality. People find change difficult especially if they have been practicing in a certain way for years, challenging deeply held beliefs concerning feeding, bowel prep etc is difficult despite good evidence backing new approaches.
13. Which would be your recommendations to any one who wants to start with a Fast Track Surgery programme?
It is important to get everyone involved and engaged in the development and the introduction of any program. The group should include surgeons, anaesthetists, nurses, dieticians, physiotherapists, theatre staff and anyone else who has contact with the patient during their hospital stay. Following agreement on the contents of the program it is important to evangelise and tell everyone in the hospital about this exciting development so that everyone backs the program and gives it their full support.