Fast-track surgery (Br J Surg 2005; 92: 3–4)

Sir There is increasing evidence to support the use of ‘fast-track’ programmes in many surgical patients and we agree that the benefit must be attributable in some way to a reduction in the stress response. The latter is, however, a vague and poorly defined term and if we are to further develop and enhance fast-track programmes (the term multimodal optimization is preferred, since the aim is not to fast-track patients but to optimize their care) a better understanding of their mode of action is needed. It is widely accepted that optimization works by preserving postoperative organ function and much emphasis has been put on attenuation of transient postoperative cardiac, respiratory and renal failure. Having completed two optimization trials1, we would suggest that of all the organ systems involved, the early return of normal gut function is pivotal. This is based on a number of observations. First, on a simplistic level, optimization is associated with an earlier tolerance of food1, a reduced postoperative ileus and a lower prevalence of postoperative nausea and vomiting2. Second, most treatment strategies included in optimization packages mainly affect the gut, such as early mobilization, synbiotics, opiate avoidance, use of epidurals, high inspired oxygen concentrations, and early enteral challenge. Third, the gastrointestinal system with its gut-associated lymphoid tissue constitutes more than 50 per cent of the body's immunological cell mass, and maintenance of normal nutrition may prevent its breakdown. This provides a rationale for the development of specific gut-directed therapies such as glutamine, antioxidants and probiotics. Research into therapies or interventions that preserve or enhance gut function should result in additional improvements to patient care.