Retrospective Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 28, 2015; 21(48): 13507-13517
Published online Dec 28, 2015. doi: 10.3748/wjg.v21.i48.13507
Use of a clinical pathway in laparoscopic gastrectomy for gastric cancer
Hee Sung Kim, Sun Oak Kim, Byung Sik Kim
Hee Sung Kim, Byung Sik Kim, Department of Gastric Surgery, Asan Medical Center, Ulsan University School of Medicine, Seoul 138-736, South Korea
Sun Oak Kim, Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Ulsan University School of Medicine, Seoul 138-736, South Korea
Author contributions: Kim HS and Kim BS designed and performed the research and wrote the paper; Kim HS collected data; Kim HS and Kim BS followed up with the patients; Kim SO performed the statistical analyses; all authors read and approved the final manuscript.
Correspondence to: Byung Sik Kim, MD, PhD, Professor of Medicine, Department of Gastric Surgery, Asan Medical Center, Ulsan University, 88, Olympic-Ro 43-Gil, Seoul 138-736, South Korea. bskim@amc.seoul.kr
Telephone: +82-2-30103491 Fax: +82-2-4749027
Received: July 8, 2015
Revised: September 20, 2015
Accepted: November 24, 2015
Published online: December 28, 2015
Abstract

AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.

METHODS: A standardized clinical pathway for gastric cancer (GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.

RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1% (n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 83.88% (n = 1740) and 84.36% (n = 2071), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications (n = 463, 9.7%) and the need for patient observation (n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54 (1.1%). In a multivariate analysis, the intraoperative events (OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male (OR = 1.459), advanced age (OR = 1.727), total gastrectomy (OR = 2.444), combined operation (OR = 1.731), and ASA score (OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.

CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.

Keywords: Clinical pathway, Laparoscopic gastrectomy, Gastric cancer, Extracorporeal anastomosis, Intracorporeal anastomosis

Core tip: Laparoscopic gastrectomy has been proven to enhance postoperative recovery compared to open gastrectomy for gastric cancer (GC) patients. Therefore, laparoscopic gastrectomy is thought to be a suitable procedure for a clinical pathway. In this study, we retrospectively analyzed the outcomes of a clinical pathway application for laparoscopic gastrectomy and tried to investigate the clinical factors that may influence a clinical pathway in a high-volume center. Laparoscopic gastrectomy for GC appears to be a good indicator for the application of a clinical pathway. For successful application, patients with risk factors (male, advanced age, total gastrectomy, combined operation, intraoperative events, American Society of Anesthesiologists score) should be managed carefully.