FTS has been already widely accepted after many types of surgeries. There are some studies demonstrate that FTS implementation in gynaecologic oncological surgery is associated with LOS decrease without increases of morbidity or readmission rates. (10,11).But in this prospective randomized clinical trial, it appears that the LOS is nearly the same between two groups. The reasons seem are as follows. First compared with general surgical oncology surgery, gynecological oncological surgery leads to less damage, almost has done no serious damage to the digestive tract. Second, compared with general surgical oncology surgery, gynecological oncological surgery hardly has a serious complication such as digestive tract fistula or leakage and death. Third, we did not include older patients (age ≥ 71 years) after discussion with the ethics committee, considering the slow recovery of digestive system and more basic diseases. Finally, part of patients continued to receive chemotherapy after surgery, and we do not discharge on the weekend or holidays, this made the criteria for discharge unstable.
We are happy to see the total cost of hospitalization (RMB) was signiﬁcantly lower in the FTS group compared with the traditional group. One of the important procedures we conducted was using a heating blanket to avoid hypothermia, keeping the intra-operative core-temperature at 36 ±0.5℃. Unintentional hypothermia is defined as an accidental low body temperature.(12)
The National Institute for Health and Care Excellence (NICE) estimates that 70% of patients admitted to the anesthetic recovery room suffer from hypothermia.(13)The accidental perioperative hypothermia is a common event during surgical interventions and increases itself perioperative morbidity impairing hemostasis, wound healing, and increasing cardiac events.(14) Because intraoperative body temperature maintenance significantly shortened the postoperative anesthesia resuscitation time, the application time of ventilator was reduced and the cost was significantly reduced. Meanwhile, fast-track surgery reduced the overall complications and complications of infections and was found statistically significant, while there was no statistical difference in some other complications. Therefore, the cost of treatment was lower than that of the traditional group.
The early oral feeding and shorter duration of intravenous infusion, reduce the costs for parenteral nutrition and prevention of thrombosis and so on. The CRP (C-Reactive protein mg/l) was also signiﬁcantly lower in the FTS group compared with the traditional group. Fasting from midnight increases insulin resistance, a complex clear carbohydrate-rich drink designed for use within 2h before anesthesia reduced hunger, thirst, anxiety as well as postoperative insulin resistance.(15) Preventing hypothermia during surgery can alleviate stress status. Numerous meta-analyses and RCTs have shown that preventing hypothermia during major abdominal surgery reduces the occurrence of wound infections.(16)
Early postoperative diet speeded up gastrointestinal motility, so we found days of fasting is much shorter in the FTS group.
In this prospective randomized trial, the cost of surgical therapy (RMB) is nearly the same between the two groups. And there was no significant difference in the cost of surgical therapy (RMB)，as the two groups had the same operators.
The incidence of total postoperative complications and lower infection rates were considered to be closely related to preoperative anxiety reduction, intraoperative temperature control, and postoperative glycaemic control. FTS program shortens preoperative and postoperative fasting time and decreases the amount of time patients staying in bed. This can be detrimental to recovery as it can result in a negative nitrogen balance.(17) The FTS program’s early oral feeding protocol assists in optimal wound healing. Research shows that unrelieved pain can inhibit the immune system, decrease gastrointestinal motility and lead to respiratory dysfunction by increasing oxygen demand.(18) As early mobility is an essential component of the FTS program, analgesia must allow mobilization and participation in recovery by the patient. Patients of ovarian cancer after appendectomy would fast until anal exhaust in the traditional sense, but early feeding proved safe and effective in the recent consensus guidelines for enhanced recovery after gastrectomy and pancreaticoduodenectomy.(19,20) It is also safe for ovarian cancer patients.
In summary, gynecological oncological surgeries have little damages to the digestive tract, so fast track surgery is appropriate and safe for them. This approach not only decreases the complications of infection also decreases the total cost of hospitalization. The ultimate benefits of FTS are improving outcomes, decreasing total cost and faster recovery.