Introduction
Enhanced recovery programmes or enhanced recovery after surgery strategies are increasingly used in medicine to reduce the length of in-patient stay following surgery.Reference Hall, Dennison, Bilku, Metcalfe and Garcea1, Reference Rawlinson, Kang, Evans and Khanna2 Enhanced recovery programmes were first developed in the 1970s, though not fully reported on until 2002.Reference Kehlet and Wilmore3 Many such programmes have now been developed, analysed, audited and modified.Reference Gravante and Elmussareh4 The literature on enhanced recovery programmes centres overwhelmingly on general surgery and colorectal surgery in particular. The programmes cover most aspects of care, including nutrition, mobilisation, wound care and patient preparation for surgery (Table I).
Tenets of enhanced recovery programmes
Enhanced recovery programmes should be safe and promote early self-care and improvement in functional performance following surgery. They may be of particular benefit following head and neck surgery because of the morbidity resulting from the surgery and the general condition of patients who undergo major head and neck surgery for malignant disease. We reviewed the published literature on enhanced recovery programmes in head and neck surgery.
Materials and methods
A systematic review of the published literature was conducted using the Embase© and PubMed© search engines. The search was performed throughout May 2013.
The key words used in the search were: ‘enhanced recovery’, ‘enhanced recovery programmes’, ‘enhanced recovery after surgery’, ‘fast-track surgery’, ‘rehabilitation’, ‘head and neck surgery’, ‘otolaryngology’, ‘oral and maxillofacial surgery’, ‘laryngectomy’, ‘free flap surgery’, ‘glossectomy’, ‘neck dissection’ and ‘pharyngectomy’. The term ‘thyroid surgery’ was excluded because enhanced recovery in this area centres on same-day surgery or day-case surgery rather than on improving patient function after surgery.
Results
A total of 3110 article abstracts were identified; 3081 were rejected because they applied to other surgical specialties. Twenty-nine articles, published between 1994 and 2013, discussed aspects of post-operative care after head and neck surgery (Figure 1). The references of these articles were reviewed and 13 articles were found to relate specifically to enhanced recovery in head and neck surgery (Table II).Reference Jensen, Todd, Block, Hegtvedt and McCulloch5–Reference Lansford, Guerriero, Kocan, Turley, Groves and Bahl17
Enhanced recovery programme review method.
List of enhanced recovery programmes and clinical care pathways
Pts = patients; op = operative; ICU = intensive care unit
Sixteen articles were discounted. Four compared different environments for the post-operative monitoring of patients who had undergone head and neck surgery.Reference Nkenke, Vairaktaris, Stelzie, Neukam and St Pierre18–Reference Arshad, Ozer, Thatcher, Old, Ozer and Agarwal21 Three described the post-operative monitoring of free tissue flaps.Reference Abdel-Galil and Mitchell22–Reference Salgado, Chim, Schoenoff and Mardini24 One discussed post-operative fluid administration to patients after head and neck surgery.Reference Bryniarska, Srinivasan, MacBean and Oloyede25 One discussed the critical care aspects of head and neck patients rather than their care,Reference Downey, Friedlander, Groeger, Kraus, Schantz and Spiro26 and another discussed the theory of critical care pathways.Reference Cohen, Stock, Andersen and Everts27 One discussed surgical complication treatment rather than prevention in head and neck reconstruction.Reference Tan, Por and Chen28 One discussed the impact of patient co-morbidity on laryngeal cancer outcomes, rather than improving patient outcomes.Reference Paleri, Wright and Davies29 One article reviewed the need for universal post-operative care in intensive therapy units.Reference Bradley30 One discussed the salvage of failed free flaps in head and neck reconstruction.Reference Novakovic, Patel, Goldstein and Gullane31 One discussed the length of hospital stay for patients who had undergone free flap reconstruction of the head and neck in general terms.Reference Ryan and Hochman32 One article was actually a review of another article on the need for intensive care admission after major head and neck surgery.Reference Morton33
Discussion
The use of enhanced recovery programmes is now established in surgery, but no accepted definition has yet been formulated describing their role or structure. One suitable definition has been provided by Hall et al.; these authors state that enhanced recovery programmes ‘represent multimodal strategies that include patient education, optimal analgesic relief, stress reduction with regional anaesthesia, focused nursing and early mobilisation to augment the rapid return to functional recovery’.Reference Hall, Dennison, Bilku, Metcalfe and Garcea1 Similarly, Rawlinson et al. described them as ‘protocol(s) … reducing complication rates following surgery and the acceleration of recovery’.Reference Rawlinson, Kang, Evans and Khanna2
A recent review by Bianchini et al. revealed that no articles on programmes described as enhanced recovery programmes or enhanced recovery after surgery strategies that related to head and neck surgery had been published.Reference Bianchini, Pelucchi, Pastore, Feo and Ciobra34 However, programmes and practices meeting the two aforementioned definitions have been published. Such programmes tend not to be identified as enhanced recovery programmes or enhanced recovery after surgery strategies because of the relatively new formal concept of enhanced recovery programmes in surgery. Additionally, the specialties that usually manage head and neck cancer patients (e.g. ENT, oral and maxillofacial surgery, and plastic surgery) manage the majority of their elective surgical cases on a day-case or same-day surgery basis, and so traditionally have little need for enhanced recovery programmes. This may also explain the lack of identified enhanced recovery programme research in this area.
Enhanced recovery programme publications related to head and neck surgery fall into two broad categories. The first category centres on early discharge from hospital following surgery using clinical care pathways. Clinical care pathways (initially referred to as ‘critical pathways’) were devised in the late 1980s to reduce the costs of healthcare.Reference Coffey, Richards, Remmert, LeRoy, Schoville and Baldwin35, Reference Heacock and Brobst36 Such pathways are defined as a ‘sequence for standardized, interdisciplinary processes or critical events that must occur for a particular case type to move the patient toward the desired outcomes within a defined period of time’.Reference Cohen, Stock, Andersen and Everts27 Judging from their definitions, enhanced recovery programmes can be distinguished from clinical care pathways, the latter of which aim to reduce the costs of care rather than encourage faster recovery, although both aim to achieve early discharge from hospital. Five clinical care pathways were identified that facilitated early recovery and discharge following surgery; these are detailed in Table II.
The second category centres on the safety of ward care without the need for intensive care monitoring. Seven articles that analysed the need for intensive monitoring after head and neck surgery were identified. Such care programmes are similar to enhanced recovery programmes in limiting unnecessary interventions. Work published in this area during the late 1990s and 2000s relating to the unnecessary care of head and neck patients in intensive care units can be viewed as a forerunner to the use of enhanced recovery programmes in head and neck surgery.
Intensive care unit admission may be required following head and neck surgery to monitor a patient's airway, and after free tissue transfer surgery with microvascular anastomosis in order to monitor flap viability and perfusion.Reference Mathew, Senthilnathan and Narayanan19 Intensive care unit admission allows optimal blood pressure control and relative immobilisation to limit shearing forces on microvascular anastomoses.Reference Arshad, Ozer, Thatcher, Old, Ozer and Agarwal21 Intensive care unit monitoring may also be required based on the patient's general state of health.Reference Bhama, Davis, Bhrany, Lam and Futran20
There can be disadvantages to intensive care unit admission though. Hypotension can result from sedation and analgesia, compromising perfusion of tissue flaps, whilst prolonged ventilation can lead to atelectasis and pneumonia development.Reference Arshad, Ozer, Thatcher, Old, Ozer and Agarwal21 Intensive care unit admission after surgery also distances the principal team from the patient, and intensive care unit nursing staff may not be as competently trained in specific aspects of care (e.g. intraoral suctioning and wound care) as nursing staff from the wards of the principal surgical team. Intensive care unit admission bears additional financial costs too, as a result of the increased level of care provided and because of operation cancellations that occur from bed shortages.Reference Mathew, Senthilnathan and Narayanan19
Mathew et al. reported no difference in tissue flap survival rates between patients admitted to intensive care units and those admitted to high dependency units, where the staff to patient ratio is lower.Reference Mathew, Senthilnathan and Narayanan19 Bhama et al. found no difference in patient outcome when post-operative patients were cared for by intensivist and non-intensivist staff.Reference Bhama, Davis, Bhrany, Lam and Futran20 This is significant as the commonest identified reason in the literature for intensive care unit admission is tissue viability monitoring, rather than respiratory support or the treatment of circulatory failure with inotrope support.Reference Godden, Patel, Baldwin and Woodwards9
Ryan and Hochman reported that tracheostomy decannulation and commencement of oral feeding could begin safely outside of hospital following major ablative surgery with free flap reconstruction.Reference Ryan and Hochman32 This allowed their department to reduce the average post-operative hospital stay to 11 days, down from 4 weeks previously; their reported patient readmission rate was 3.2 per cent.
Arshad et al. reported no difference in post-operative medical or surgical complications in patients who were cared for in a non-intensive care unit setting (compared with those cared for in an intensive care unit); the only difference was the length of hospital stay, which was reduced for those patients who returned to a general head and neck ward after surgery.Reference Arshad, Ozer, Thatcher, Old, Ozer and Agarwal21
Godden et al. reported that intensive care unit admission did not influence the success or failure of free flap transfer surgery, suggesting that tissue flap monitoring could be undertaken safely on a general ward.Reference Godden, Patel, Baldwin and Woodwards9 Tracheostomy may be an unnecessary standard intervention following head and neck oncology surgery, as discussed by Crosher et al.Reference Crosher, Baldie and Mitchell6 These authors suggested that only mandible, floor of mouth and posterior tongue resections required this intervention, to avoid flap disturbance and maintain a patent airway (as post-operative tissue swelling may compromise the airway).
Enhanced recovery associated with the comparatively less extensive thyroid surgery has met with limited success. The sole aim of enhanced recovery for thyroid patients appears to be same-day discharge, allowing thyroid surgery to be performed as a day-case operation, for which it was deemed suitable in 2001. The main concern remains post-operative haemorrhage with resulting airway compression. Whilst Chin et al. reported that same-day discharge from an ambulatory unit for selected patients was possible,Reference Chin, Loh and Tan37 a review article by Doran et al. suggested that post-operative haemorrhage is too unpredictable for thyroid surgery to be performed as a day-case operation.Reference Doran, England and Palazzo38
Published articles on enhanced recovery programmes relating to head and neck surgery may assist surgeons and critical care staff in facilitating earlier recovery following surgery. Speedier recovery may improve patient functioning, reduce complications and permit earlier hospital discharge. In practice, informal enhanced recovery programmes probably do exist in most departments undertaking head and neck surgery; these are likely to be based on the lead clinicians' experience, and on the personal preferences of the unit and hospital. Such programmes may well be awaiting audit and publication. The levels of evidence available at the time of our search reach level 2b. Currently though, comparatively little work is available for head and neck surgeons to draw on, especially when compared to the six randomised, controlled trials and seven case-controlled trials of enhanced recovery programmes in colorectal surgery as of 2011.
The issues that need further study include the use of pre-operative enteral and parenteral nutrition in enhancing post-operative recovery, the early removal of surgical drains, the prompt fitting of speech valve prostheses, and the early return of oral feeding.
Enhanced recovery programmes cannot be uniformly applied to all patients undergoing head and neck surgery. Variations within and between programmes will occur based on surgeons' technical abilities, patient's understanding, hospital unit skills and resources, staffing levels and staff experience. However, head and neck surgeons may be able to apply those enhanced recovery programmes already in use to their own practice, and reflect on and apply the work of other surgical specialties to the care of their patients.
